CO Medicaid Community Behavioral Health Services -- 8.212
8.212 COMMUNITY BEHAVIORAL HEALTH SERVICES
8.212.1 ENROLLMENT
8.212.1.A. The following individuals are not eligible for enrollment in the Community Behavioral Health Services program:
1. Qualified Medicare Beneficiary only (QMB-only).
2. Qualified Disabled and Working Individuals (QDWI)
3. Qualified Individuals 1 (QI 1).
4. Special Low Income Medicare Beneficiaries (SLMB).
5. Undocumented aliens, including non-qualified, undocumented and qualified aliens who have not met the five-year bar who are eligible for Federal Medicaid for care and services related to the treatment of an approved medical condition.
6. Individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE).
7. Individuals who are inpatient at the Colorado Mental Health Institute at Pueblo or the Colorado Mental Health Institute at Fort Logan who are:
a. Found by a criminal court to be Not Guilty by Reason of Insanity (NGRI);
b. Found by a criminal court to be Incompetent to Proceed (ITP); or
c. Ordered by a criminal court to a State Institute for Mental Disease (IMD) for evaluation (eg. Competency to proceed, sanity, conditional release revocation, pre-sentencing). 8. Individuals between ages 21 and 64 who receive inpatient treatment who are inpatient at the Colorado Mental Health Institute at Pueblo or the Colorado Mental Health Institute at Fort Logan.
9. Individuals who are NGRI and who are in the community on Temporary Physical Removal (TPR) from the Colorado Mental Health Institute at Pueblo and who are eligible for Medicaid are exempted from the Community Behavioral Health Services program while they are on TPR. TPR individuals remain under the control and care of the Institute.
10. Classes of individuals determined by the Department to require exclusion from the Community Behavioral Health Services program, defined as individuals residing in State Regional Centers for people with developmental disabilities and associated satellite residences for more than 90 days.
11. Individuals who receive an individual exemption as set forth at Section 8.212.2.
12. Individuals while determined presumptively eligible for Medicaid.
13. Children or youth in the custody of the Colorado Department of Human Services -Division of Child Welfare or Division of Youth Corrections who are placed by those agencies in a Psychiatric Residential Treatment Facility (PRTF) as defined in C.R.S. 25.5-4-103 or a Residential Child Care Facility (RCCF) as defined in C.R.S. 26-6-102.
8.212.1.B. All other Medicaid clients shall be enrolled in the Community Behavioral Health Services program, into a behavioral health organization in the client’s geographic area.
1. The Department automatically re-enrolls a client into the same behavioral health organization if there is a loss of Medicaid eligibility of two months or less.
8.212.2 INDIVIDUAL EXEMPTIONS
8.212.2.A. A client may request to be exempt from enrollment in the Community Behavioral Health Services program if:
1. The client has a clinical relationship with a provider of behavioral health services that the client wishes to maintain and that provider is not part of the provider network of the behavioral health organization in the client’s geographic area, or
2. The client and the behavioral health organization have been unable to develop a healthy working relationship and continued enrollment would not be in the best clinical interest of the client.
8.212.2.B. If the client requests an exemption because the client’s existing provider is not in the provider network, based on Section 8.212.2.A.1:
1. The client shall notify the behavioral health organization of his/her request to receive necessary behavioral health services from the provider with whom the client has established a clinical relationship.
2. Within fourteen (14) calendar days of receiving notice from the client, the behavioral health organization shall determine whether it can contract with the client’s chosen provider to provide necessary behavioral health services to the client and provide written notice to the client and the client’s provider of that determination.
3. If the behavioral health organization is unable to approve the client’s request, the notice shall:
a. Identify one or more providers within the behavioral health organization’s network who can appropriately meet the client’s behavioral health needs;
b. Include information on the client’s right to request an exemption, the process for requesting an exemption and assistance available to the client.
4. The client may request an exemption with the Department within fourteen (14) calendar days of the date of the notice from the behavioral health organization disapproving the client’s request.
5. Within thirty (30) calendar days after receipt of the client’s request for exemption, the Department shall provide written notice of its determination to the client, the client’s provider and the behavioral health organization.
8.212.2.C. If the client requests an exemption because continued enrollment would not be in the best clinical interest of the client, based on Section 8.212.2.A.2:
1. The client shall request an exemption from the Department.
2. Within thirty (30) calendar days after receipt of the client’s request for exemption, the Department shall provide written notice of its determination to the client, the client’s provider and the behavioral health organization.
8.212.2.D. A client whose request for exemption has been denied by the Department has the right to appeal the determination pursuant to Section 8.057.
8.212.2.E. A newly Medicaid eligible client who requests an exemption shall be enrolled in the Community Behavioral Health Services program pending the outcome of the request for exemption and any appeal pursuant to Section 8.057.
8.212.2.F. A client who is enrolled in the Community Behavioral Health Services program and is requesting an exemption shall continue to be enrolled in the Community Behavioral Health Services program pending the outcome of the request for exemption and any appeal pursuant to Section 8.057.
8.212.2.G. A client who wants to re-enroll in the Community Behavioral Health Services program shall notify the Department. The client will be re-enrolled within thirty (30) calendar days of receipt of the client’s request. The Department shall notify the client and the behavioral health organization of the re-enrollment prior to the effective date of re-enrollment.
8.212.2.H. A client who has been exempted from enrollment in the Community Behavioral Health Services program because the program was not in the best clinical interest of the client, as described in Section 8.212.2.A.2, may be re-enrolled by the Department into the Community Behavioral Health Services program after a period of exemption, if the client demonstrates a clear need for a behavioral health organization to manage his or her behavioral health care.
1. The Department shall notify the client and the behavioral health organization of the reenrollment at least ten (10) calendar days prior to the effective date of re-enrollment.
8.212.3 CLIENT RIGHTS AND PROTECTIONS
8.212.3.A. A client enrolled in the Community Behavioral Health Services program shall have the following rights and protections:
1. To be treated with respect and with due consideration for his/her dignity and privacy.
2. To receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand.
3. To participate in decisions regarding his/her health care, including the right to refuse treatment and the right to a second opinion.
4. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
5. To request and receive a copy of his/her medical records and to request that they be amended or corrected, as specified in 45 CFR Part 164.
6. To exercise his/her rights without any adverse effect on the way he/she is treated.
7. To enforce, pursuant to Section 8.209, the provisions of the community behavioral health services contracting regarding rights or duties owed to the client under the contract.
8.212.4 BEHAVIORAL HEALTH SERVICES
8.212.4.A. The following are required services of the Community Behavioral Health Services program:
1. Inpatient Psychiatric Hospital Services:
a. Under age 21 -- A program of psychiatric care in which the client remains 24 hours a day in a psychiatric hospital, State Institute for Mental Disease (IMD), or other facility licensed as a hospital by the State.
b. Adults ages 21-64 -- A program of psychiatric care in which the client remains 24 hours a day in a psychiatric hospital, or other facility licensed as a hospital by the State, excluding State Institutes of Mental Disease (IMD).
c. Adults ages 65 and over -- A program of care in which the client remains 24 hours a day in a psychiatric hospital, State Institute for Mental Disease (IMD), or other facility licensed as a hospital by the State.
2. Outpatient Services -- A program of care in which the client receives services in a hospital or other health care facility, but does not remain in the facility 24 hours a day, including:
a. Physician Services, including psychiatric care – Behavioral health services provided within the scope of practice of medicine as defined by State law.
b. Rehabilitative Services – Any remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of behavioral/emotional disability and restoration of a client to his/her best possible functional level, including: i. Individual Behavioral Health Therapy - Therapeutic contact with one client of more than30 minutes, but no more than two (2) hours.
ii. Individual Brief Behavioral Health Therapy- Therapeutic contact with one client of up to and including 30 minutes.
Iii Group Behavioral Health Therapy- Therapeutic contact with more than one client, of up to and including two (2) hours.
iv. Family Behavioral Health Therapy– Face to face therapeutic contact with a client and family member(s), or other persons significant to the client, for improving client-family functioning. Family behavioral health therapy is appropriate when intervention in the family interactions is expected to improve the client’s emotional/behavioral health. The primary purpose of family behavioral health therapy is treatment of the client.
v. Behavioral Health Assessment – Face to face clinical assessment of a client by a behavioral health professional that determines the nature of the client’s problem(s), factors contributing to the problem(s), a client’s strengths, abilities and resources to help solve the problem(s), and any existing diagnoses.
vi. Pharmacologic Management – Monitoring of medications prescribed and consultation provided to clients by a physician or other medical practitioner authorized to prescribe medications as defined by State law, including associated laboratory services, as indicated.
vii. Outpatient Day Treatment – Therapeutic contact with a client in a structured, non-residential program of therapeutic activities lasting more than four (4) hours but less than twenty-four (24) hours per day. Services include assessment and monitoring; individual/group/family therapy; psychological testing; medical/nursing support; psychosocial education; skill development and socialization training focused on improving functional and behavioral deficits; medication management; expressive and activity therapies; and coordination of needed services with other agencies. When provided in an outpatient hospital program, may be called “partial hospitalization.”
viii. Emergency/Crisis Services - Services provided during a behavioral health emergency which involve unscheduled, immediate, or special interventions in response to crisis situation with a client, including associated laboratory services, as indicated.
3. Pharmacy Services – Prescribed drugs when used in accordance with 10 CCR 2505-10 Section 8.800, Pharmaceuticals.
4. Targeted Case Management – Case management services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services.
5. School-Based Behavioral Health Services - Behavioral health services provided to school-aged children and adolescents on-site in their schools, with the cooperation of the schools.
6. Drug Screening and Monitoring – Substance use disorder counseling services provided along with screening results to be discussed with client.
7. Detoxification Services – Services relating to detoxification including all of the following: Physical assessment of detox progression including vital signs monitoring; level of motivation assessment for treatment evaluation; provision of daily living needs (includes hydration, nutrition, cleanliness and toiletry); safety assessment, including suicidal ideation and other behavioral health issues.
8. Medication-Assisted Treatment – Administration of Methadone or another approved controlled substance to an opiate-dependent person for the purpose of decreasing or eliminating dependence on opiate substances.
8.212.4.B. Alternative services of the Community Behavioral Health Services program are:
1. Vocational -- Services designed to help adult and adolescent clients who are ineligible for state vocational rehabilitation services to gain employment skills and employment. Services are skill and support development interventions, educational services, vocational assessment, and job coaching.
2. Assertive Community Treatment (ACT) – Comprehensive, locally-based, individualized treatment for adults with serious behavioral health disorders, that is available 24 hours a day, 365 days a year. Services include case management, initial and ongoing behavioral health assessment, psychiatric services, employment and housing assistance, family support and education, and substance use disorders services.
3. Intensive Case Management -- Community-based services averaging more than one hour per week, provided to adults with serious behavioral health disorders who are at risk of a more intensive 24 hour placement and who need extra support to live in the community. Services are assessment, care plan development, multi-system referrals, assistance with wraparound and supportive living services, monitoring and follow-up. Intensive case management may be provided to children/youth under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program.
4. Clubhouse and drop-in center services – Peer support services for people who have behavioral health disorders, provided in a Clubhouse or Drop-In Center setting. Clubhouse participants may use their skills for clerical work, data input, meal preparation, providing resource information and outreach to clients. Drop-in Centers offer planned activities and opportunities for individuals to interact socially, promoting and supporting recovery.
5. Recovery Services – Community-based services that promote self-management of behavioral health symptoms, relapse prevention, treatment choices, mutual support, enrichment, rights protection, social supports. Services are peer counseling and support services, peer-run drop-in centers, peer-run employment services, peer mentoring, consumer and family support groups, warm lines, and advocacy services.
6. Residential Services – Twenty-four (24) hour care, excluding room and board, provided in a non-hospital, non-nursing home setting, appropriate for adults whose mental health issues and symptoms are severe enough to require a 24-hour structured program but do not require hospitalization. Services are provided in the setting where the client is living, in real-time, with immediate interventions available as needed. Clinical interventions are assessment and monitoring of mental and physical health status; assessment and monitoring of safety; assessment of/support for motivation for treatment; assessment of ability to provide for daily living needs; observation and assessment of group interactions; individual , group and family therapy; medication management; and behavioral interventions. Residential services may be provided to children/youth under EPSDT.
7. Prevention/Early Intervention Services – Proactive efforts to educate and empower individuals to choose and maintain healthy life behaviors and lifestyles that promote positive behavioral health. Services include behavioral health screenings; educational programs promoting safe and stable families; senior workshops related to aging disorders; and parenting skills classes.
8. Respite Care – Temporary or short-term care of a child, youth or adult client provided by adults other than the birth parents, foster/adoptive parents, family members or caregivers that the client normally resides with. Respite is designed to give the caregivers some time away from the client to allow them to emotionally recharge and become better prepared to handle normal day-to-day challenges. Respite care providers are specially trained to serve individuals with behavioral health issues.
8.212.5 EMERGENCY SERVICES
8.212.5.A. A client enrolled in the Community Behavioral Health Services program shall seek all behavioral health services from the behavioral health organization with which he/she is enrolled except as specified in 8.212.5.B.
8.212.5.B. Clients with an emergency medical condition may seek emergency services outside of the network of the behavioral health organization in which they are enrolled.
8.212.5.C. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention or behavioral health services to result in the following:
1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) or the health of another in serious jeopardy.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.
8.212.5.D. Emergency services means covered inpatient and outpatient services that are as follows:
1. Furnished by a provider that is qualified to furnish these services.
2. Needed to evaluate or stabilize an emergency medical condition.
8.212.6 ESSENTIAL COMMUNITY PROVIDERS
8.212.6.A. In order to be eligible for designation as an Essential Community Provider, the following health care providers shall be determined to have historically served medically needy or medically indigent patients and demonstrated a commitment to serve low-income and medically indigent populations who make up a significant portion of their patient population or, in the case of a sole community provider, serve the medically indigent patients within their medical capability:
1. Disproportionate share hospitals.
2. Local county and district health departments, county nursing services and regional health department operating pursuant to Title 25, C.R.S., as amended.
3. Federally Qualified Health Centers (FQHCs).
4. School based health centers that can verify that 25% of students enrolled in the school are at or below 185% of the Federal Poverty Level and that services are offered to the entire student population enrolled in the school without regard to the patient’s ability to pay.
5. Family Medicine Residency Training Programs that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
6. Rural Health Clinics that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
7. State certified Title X Family Planning Agencies that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
8. Sole community providers that are not located within a metropolitan statistical area, as designated by the U.S. Office of Management and Budget, and in whose community there is no other similar type of health care and the provider can verify that it provides health care services to patients below 185% of the Federal Poverty Level within its medical capability.
9. New health care providers operating under a sponsoring or participating entity that qualifies as an Essential Community Provider.
10. Health care providers that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
8.212.6.B. In order to be eligible for designation as an Essential Community Provider, the provider shall waive charges or charge for services on a sliding scale for patients/families at or below 185% of the Federal Poverty Level.
8.212.6.C. Health care providers, except those set forth a 8.212.6.A(1) through (3), who seek to be designated as an Essential Community Provider, shall submit their application, including a copy of their sliding fee scale to the Department.
8.212.1 ENROLLMENT
8.212.1.A. The following individuals are not eligible for enrollment in the Community Behavioral Health Services program:
1. Qualified Medicare Beneficiary only (QMB-only).
2. Qualified Disabled and Working Individuals (QDWI)
3. Qualified Individuals 1 (QI 1).
4. Special Low Income Medicare Beneficiaries (SLMB).
5. Undocumented aliens, including non-qualified, undocumented and qualified aliens who have not met the five-year bar who are eligible for Federal Medicaid for care and services related to the treatment of an approved medical condition.
6. Individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE).
7. Individuals who are inpatient at the Colorado Mental Health Institute at Pueblo or the Colorado Mental Health Institute at Fort Logan who are:
a. Found by a criminal court to be Not Guilty by Reason of Insanity (NGRI);
b. Found by a criminal court to be Incompetent to Proceed (ITP); or
c. Ordered by a criminal court to a State Institute for Mental Disease (IMD) for evaluation (eg. Competency to proceed, sanity, conditional release revocation, pre-sentencing). 8. Individuals between ages 21 and 64 who receive inpatient treatment who are inpatient at the Colorado Mental Health Institute at Pueblo or the Colorado Mental Health Institute at Fort Logan.
9. Individuals who are NGRI and who are in the community on Temporary Physical Removal (TPR) from the Colorado Mental Health Institute at Pueblo and who are eligible for Medicaid are exempted from the Community Behavioral Health Services program while they are on TPR. TPR individuals remain under the control and care of the Institute.
10. Classes of individuals determined by the Department to require exclusion from the Community Behavioral Health Services program, defined as individuals residing in State Regional Centers for people with developmental disabilities and associated satellite residences for more than 90 days.
11. Individuals who receive an individual exemption as set forth at Section 8.212.2.
12. Individuals while determined presumptively eligible for Medicaid.
13. Children or youth in the custody of the Colorado Department of Human Services -Division of Child Welfare or Division of Youth Corrections who are placed by those agencies in a Psychiatric Residential Treatment Facility (PRTF) as defined in C.R.S. 25.5-4-103 or a Residential Child Care Facility (RCCF) as defined in C.R.S. 26-6-102.
8.212.1.B. All other Medicaid clients shall be enrolled in the Community Behavioral Health Services program, into a behavioral health organization in the client’s geographic area.
1. The Department automatically re-enrolls a client into the same behavioral health organization if there is a loss of Medicaid eligibility of two months or less.
8.212.2 INDIVIDUAL EXEMPTIONS
8.212.2.A. A client may request to be exempt from enrollment in the Community Behavioral Health Services program if:
1. The client has a clinical relationship with a provider of behavioral health services that the client wishes to maintain and that provider is not part of the provider network of the behavioral health organization in the client’s geographic area, or
2. The client and the behavioral health organization have been unable to develop a healthy working relationship and continued enrollment would not be in the best clinical interest of the client.
8.212.2.B. If the client requests an exemption because the client’s existing provider is not in the provider network, based on Section 8.212.2.A.1:
1. The client shall notify the behavioral health organization of his/her request to receive necessary behavioral health services from the provider with whom the client has established a clinical relationship.
2. Within fourteen (14) calendar days of receiving notice from the client, the behavioral health organization shall determine whether it can contract with the client’s chosen provider to provide necessary behavioral health services to the client and provide written notice to the client and the client’s provider of that determination.
3. If the behavioral health organization is unable to approve the client’s request, the notice shall:
a. Identify one or more providers within the behavioral health organization’s network who can appropriately meet the client’s behavioral health needs;
b. Include information on the client’s right to request an exemption, the process for requesting an exemption and assistance available to the client.
4. The client may request an exemption with the Department within fourteen (14) calendar days of the date of the notice from the behavioral health organization disapproving the client’s request.
5. Within thirty (30) calendar days after receipt of the client’s request for exemption, the Department shall provide written notice of its determination to the client, the client’s provider and the behavioral health organization.
8.212.2.C. If the client requests an exemption because continued enrollment would not be in the best clinical interest of the client, based on Section 8.212.2.A.2:
1. The client shall request an exemption from the Department.
2. Within thirty (30) calendar days after receipt of the client’s request for exemption, the Department shall provide written notice of its determination to the client, the client’s provider and the behavioral health organization.
8.212.2.D. A client whose request for exemption has been denied by the Department has the right to appeal the determination pursuant to Section 8.057.
8.212.2.E. A newly Medicaid eligible client who requests an exemption shall be enrolled in the Community Behavioral Health Services program pending the outcome of the request for exemption and any appeal pursuant to Section 8.057.
8.212.2.F. A client who is enrolled in the Community Behavioral Health Services program and is requesting an exemption shall continue to be enrolled in the Community Behavioral Health Services program pending the outcome of the request for exemption and any appeal pursuant to Section 8.057.
8.212.2.G. A client who wants to re-enroll in the Community Behavioral Health Services program shall notify the Department. The client will be re-enrolled within thirty (30) calendar days of receipt of the client’s request. The Department shall notify the client and the behavioral health organization of the re-enrollment prior to the effective date of re-enrollment.
8.212.2.H. A client who has been exempted from enrollment in the Community Behavioral Health Services program because the program was not in the best clinical interest of the client, as described in Section 8.212.2.A.2, may be re-enrolled by the Department into the Community Behavioral Health Services program after a period of exemption, if the client demonstrates a clear need for a behavioral health organization to manage his or her behavioral health care.
1. The Department shall notify the client and the behavioral health organization of the reenrollment at least ten (10) calendar days prior to the effective date of re-enrollment.
8.212.3 CLIENT RIGHTS AND PROTECTIONS
8.212.3.A. A client enrolled in the Community Behavioral Health Services program shall have the following rights and protections:
1. To be treated with respect and with due consideration for his/her dignity and privacy.
2. To receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand.
3. To participate in decisions regarding his/her health care, including the right to refuse treatment and the right to a second opinion.
4. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
5. To request and receive a copy of his/her medical records and to request that they be amended or corrected, as specified in 45 CFR Part 164.
6. To exercise his/her rights without any adverse effect on the way he/she is treated.
7. To enforce, pursuant to Section 8.209, the provisions of the community behavioral health services contracting regarding rights or duties owed to the client under the contract.
8.212.4 BEHAVIORAL HEALTH SERVICES
8.212.4.A. The following are required services of the Community Behavioral Health Services program:
1. Inpatient Psychiatric Hospital Services:
a. Under age 21 -- A program of psychiatric care in which the client remains 24 hours a day in a psychiatric hospital, State Institute for Mental Disease (IMD), or other facility licensed as a hospital by the State.
b. Adults ages 21-64 -- A program of psychiatric care in which the client remains 24 hours a day in a psychiatric hospital, or other facility licensed as a hospital by the State, excluding State Institutes of Mental Disease (IMD).
c. Adults ages 65 and over -- A program of care in which the client remains 24 hours a day in a psychiatric hospital, State Institute for Mental Disease (IMD), or other facility licensed as a hospital by the State.
2. Outpatient Services -- A program of care in which the client receives services in a hospital or other health care facility, but does not remain in the facility 24 hours a day, including:
a. Physician Services, including psychiatric care – Behavioral health services provided within the scope of practice of medicine as defined by State law.
b. Rehabilitative Services – Any remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of behavioral/emotional disability and restoration of a client to his/her best possible functional level, including: i. Individual Behavioral Health Therapy - Therapeutic contact with one client of more than30 minutes, but no more than two (2) hours.
ii. Individual Brief Behavioral Health Therapy- Therapeutic contact with one client of up to and including 30 minutes.
Iii Group Behavioral Health Therapy- Therapeutic contact with more than one client, of up to and including two (2) hours.
iv. Family Behavioral Health Therapy– Face to face therapeutic contact with a client and family member(s), or other persons significant to the client, for improving client-family functioning. Family behavioral health therapy is appropriate when intervention in the family interactions is expected to improve the client’s emotional/behavioral health. The primary purpose of family behavioral health therapy is treatment of the client.
v. Behavioral Health Assessment – Face to face clinical assessment of a client by a behavioral health professional that determines the nature of the client’s problem(s), factors contributing to the problem(s), a client’s strengths, abilities and resources to help solve the problem(s), and any existing diagnoses.
vi. Pharmacologic Management – Monitoring of medications prescribed and consultation provided to clients by a physician or other medical practitioner authorized to prescribe medications as defined by State law, including associated laboratory services, as indicated.
vii. Outpatient Day Treatment – Therapeutic contact with a client in a structured, non-residential program of therapeutic activities lasting more than four (4) hours but less than twenty-four (24) hours per day. Services include assessment and monitoring; individual/group/family therapy; psychological testing; medical/nursing support; psychosocial education; skill development and socialization training focused on improving functional and behavioral deficits; medication management; expressive and activity therapies; and coordination of needed services with other agencies. When provided in an outpatient hospital program, may be called “partial hospitalization.”
viii. Emergency/Crisis Services - Services provided during a behavioral health emergency which involve unscheduled, immediate, or special interventions in response to crisis situation with a client, including associated laboratory services, as indicated.
3. Pharmacy Services – Prescribed drugs when used in accordance with 10 CCR 2505-10 Section 8.800, Pharmaceuticals.
4. Targeted Case Management – Case management services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services.
5. School-Based Behavioral Health Services - Behavioral health services provided to school-aged children and adolescents on-site in their schools, with the cooperation of the schools.
6. Drug Screening and Monitoring – Substance use disorder counseling services provided along with screening results to be discussed with client.
7. Detoxification Services – Services relating to detoxification including all of the following: Physical assessment of detox progression including vital signs monitoring; level of motivation assessment for treatment evaluation; provision of daily living needs (includes hydration, nutrition, cleanliness and toiletry); safety assessment, including suicidal ideation and other behavioral health issues.
8. Medication-Assisted Treatment – Administration of Methadone or another approved controlled substance to an opiate-dependent person for the purpose of decreasing or eliminating dependence on opiate substances.
8.212.4.B. Alternative services of the Community Behavioral Health Services program are:
1. Vocational -- Services designed to help adult and adolescent clients who are ineligible for state vocational rehabilitation services to gain employment skills and employment. Services are skill and support development interventions, educational services, vocational assessment, and job coaching.
2. Assertive Community Treatment (ACT) – Comprehensive, locally-based, individualized treatment for adults with serious behavioral health disorders, that is available 24 hours a day, 365 days a year. Services include case management, initial and ongoing behavioral health assessment, psychiatric services, employment and housing assistance, family support and education, and substance use disorders services.
3. Intensive Case Management -- Community-based services averaging more than one hour per week, provided to adults with serious behavioral health disorders who are at risk of a more intensive 24 hour placement and who need extra support to live in the community. Services are assessment, care plan development, multi-system referrals, assistance with wraparound and supportive living services, monitoring and follow-up. Intensive case management may be provided to children/youth under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program.
4. Clubhouse and drop-in center services – Peer support services for people who have behavioral health disorders, provided in a Clubhouse or Drop-In Center setting. Clubhouse participants may use their skills for clerical work, data input, meal preparation, providing resource information and outreach to clients. Drop-in Centers offer planned activities and opportunities for individuals to interact socially, promoting and supporting recovery.
5. Recovery Services – Community-based services that promote self-management of behavioral health symptoms, relapse prevention, treatment choices, mutual support, enrichment, rights protection, social supports. Services are peer counseling and support services, peer-run drop-in centers, peer-run employment services, peer mentoring, consumer and family support groups, warm lines, and advocacy services.
6. Residential Services – Twenty-four (24) hour care, excluding room and board, provided in a non-hospital, non-nursing home setting, appropriate for adults whose mental health issues and symptoms are severe enough to require a 24-hour structured program but do not require hospitalization. Services are provided in the setting where the client is living, in real-time, with immediate interventions available as needed. Clinical interventions are assessment and monitoring of mental and physical health status; assessment and monitoring of safety; assessment of/support for motivation for treatment; assessment of ability to provide for daily living needs; observation and assessment of group interactions; individual , group and family therapy; medication management; and behavioral interventions. Residential services may be provided to children/youth under EPSDT.
7. Prevention/Early Intervention Services – Proactive efforts to educate and empower individuals to choose and maintain healthy life behaviors and lifestyles that promote positive behavioral health. Services include behavioral health screenings; educational programs promoting safe and stable families; senior workshops related to aging disorders; and parenting skills classes.
8. Respite Care – Temporary or short-term care of a child, youth or adult client provided by adults other than the birth parents, foster/adoptive parents, family members or caregivers that the client normally resides with. Respite is designed to give the caregivers some time away from the client to allow them to emotionally recharge and become better prepared to handle normal day-to-day challenges. Respite care providers are specially trained to serve individuals with behavioral health issues.
8.212.5 EMERGENCY SERVICES
8.212.5.A. A client enrolled in the Community Behavioral Health Services program shall seek all behavioral health services from the behavioral health organization with which he/she is enrolled except as specified in 8.212.5.B.
8.212.5.B. Clients with an emergency medical condition may seek emergency services outside of the network of the behavioral health organization in which they are enrolled.
8.212.5.C. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention or behavioral health services to result in the following:
1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) or the health of another in serious jeopardy.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.
8.212.5.D. Emergency services means covered inpatient and outpatient services that are as follows:
1. Furnished by a provider that is qualified to furnish these services.
2. Needed to evaluate or stabilize an emergency medical condition.
8.212.6 ESSENTIAL COMMUNITY PROVIDERS
8.212.6.A. In order to be eligible for designation as an Essential Community Provider, the following health care providers shall be determined to have historically served medically needy or medically indigent patients and demonstrated a commitment to serve low-income and medically indigent populations who make up a significant portion of their patient population or, in the case of a sole community provider, serve the medically indigent patients within their medical capability:
1. Disproportionate share hospitals.
2. Local county and district health departments, county nursing services and regional health department operating pursuant to Title 25, C.R.S., as amended.
3. Federally Qualified Health Centers (FQHCs).
4. School based health centers that can verify that 25% of students enrolled in the school are at or below 185% of the Federal Poverty Level and that services are offered to the entire student population enrolled in the school without regard to the patient’s ability to pay.
5. Family Medicine Residency Training Programs that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
6. Rural Health Clinics that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
7. State certified Title X Family Planning Agencies that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
8. Sole community providers that are not located within a metropolitan statistical area, as designated by the U.S. Office of Management and Budget, and in whose community there is no other similar type of health care and the provider can verify that it provides health care services to patients below 185% of the Federal Poverty Level within its medical capability.
9. New health care providers operating under a sponsoring or participating entity that qualifies as an Essential Community Provider.
10. Health care providers that can verify that 25% of the patients served are at or below 185% of the Federal Poverty Level.
8.212.6.B. In order to be eligible for designation as an Essential Community Provider, the provider shall waive charges or charge for services on a sliding scale for patients/families at or below 185% of the Federal Poverty Level.
8.212.6.C. Health care providers, except those set forth a 8.212.6.A(1) through (3), who seek to be designated as an Essential Community Provider, shall submit their application, including a copy of their sliding fee scale to the Department.