This document addresses intensive in-home behavioral health services (II-HBHS). II-HBHS are a range of therapy services provided face-to-face in the home to address symptoms and behaviors that, as the result of a psychiatric disorder or substance use disorder, put the members and others at risk of harm. “Home” describes a family living arrangement that reflects a sustained (months to lifetime) commitment to the member, that is, a commitment based on parenthood, marriage, kinship, adoption, guardianship, or other close personal relationship. The provided service includes member and family interventions intended to help the member and family, especially responsible adults, to address the symptoms and behaviors related to a psychiatric disorder or substance use disorder in a caring fashion that reduces the risk of harm with the goal of returning the member to a status where services can be continued in a setting outside the home. Intensity or hours of II-HBHS is tied to the risk of harm through a treatment plan and goals that specify how hours of service, greater than those typical of office or clinic care, (which is usually no more than an hour per visit and often less than every week), are needed to reduce risk and improve health. A description of the critical relationship between the home environment and the symptoms and behaviors that create risk is a necessary component of the treatment plan. Treatment in the home that addresses individual and family issues related to the setting separates II-HBHS from facility-based services, such as Partial Hospital Programs (PHP) and Intensive Outpatient Programs (IOP). Achieving harm reduction and improved health are anticipated to result in use of office-based services.

The medical necessity criteria outlined in this document relating to psychiatric disorders or mood/behavior disturbance treatment includes two categories; Severity of Illness and Continued Stay. Severity of Illness criteria include descriptions of the member’s condition and circumstances. For continued authorization of the requested service, Continued Stay criteria must be met, along with Severity of Illness criteria.

The member’s symptoms or condition should meet diagnostic criteria for a behavioral health condition, as defined in the most recent edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD). The diagnosis should be consistent with symptoms and the primary focus of treatment.

Note: Benefits, state mandates and regulatory requirements should be verified prior to application of criteria listed below. This document does not address Adaptive Behavioral Treatment (ABT) or Applied Behavior Analysis (ABA).

Please see the following related documents for additional information:

• CG-BEH-02 Adaptive Behavioral Treatment
• CG-MED-19 Custodial Care
• CG-MED-23 Home Health

Clinical Indications

Medically Necessary:

Intensive in-home behavioral health services may be considered medically necessary when ALL of the following selection criteria are met (A, B and C):

1. There is documentation that all of the following Severity of Illness criteria are met (1 through 7):
   1. Specific psychiatric symptoms or disturbances of mood or behavior, consistent with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders/International Classification of Diseases diagnosis listed, are linked to functional impairment and risk of serious harm; and
   2. There are specific deficits directly related to the intensive in-home behavioral health services; and
   3. The member and significant others demonstrate motivation for treatment, are capable of benefiting from the treatment approach planned, and participate in treatment; and
   4. The symptoms and functional impairment associated with the individual’s psychiatric disorder or mood/behavioral disturbance are expected to improve with intensive in-home behavioral health services based on targeting achievable individual goals; and
   5. There is a described risk for behavioral or functional regression without intensive in-home behavioral health services; and
   6. There is demonstrated evidence of significant variability in the day-to-day capacity of the member to cope with life situations; and
   7. There is need for direct monitoring less than daily but more often than weekly; and
2. A diagnosis has been documented by a licensed medical professional acting within their scope of licensed practice which confirms a psychiatric diagnosis or significant mood or behavioral disturbance, as defined within the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases; and
3. A person-centered treatment plan has been developed that includes all of the following (1 through 4):
   1. Identifies specific behavioral, psychological, family-based, or community-based behavioral impairments or symptoms that interfere with normal functions, (which may include social, adaptive, psychological or other functional impairments to performing activities of daily living and social interactions); and
   2. Specific individual age-appropriate goals have been documented which can be objectively measured based on standardized assessments related to the diagnosed condition or conditions and linked to specific targeted symptoms, behaviors and functional impairments which are to be addressed by the treatment plan*; and
   3. A specific timeline is documented in the treatment plan which specifies the intensity of services (number of visits per week and hours per visit) and duration of intensive in-home behavioral health services, (which is usually not less than for 1 month and not more than for 6 months), after which a follow/up re-evaluation is to be performed by an appropriately licensed medical professional for the purpose of determining the individual’s symptomatic or behavioral progress and possible need for continuation of services; and
   4. Specific intensive in-home behavioral health services are to be delivered by appropriately licensed or certified providers acting within their respective scopes of practice.

*Note: Each goal specified within the individualized treatment plan should include documentation of:

• Baseline behavioral measurements of function; and
• The individual’s symptomatic or behavioral progress, to date, with assessment of specific measures of progress made (for example, in areas such as social skills, communication skills, activities of daily living or specifically targeted functional impairments); and
• The anticipated duration of treatment which includes a timeline for achievement based on both the initial assessment and subsequent reassessments to be performed not less often than every 4 weeks. The duration of treatment, along with the treatment plan goals and documented behavioral progress, is to be reassessed every month over the duration of the intensive in-home behavioral health services interventions initially considered medically necessary when the above criteria are met.

Continuation of intensive in-home behavioral health services is considered medically necessary when the member continues to meet Severity of Illness criteria (see above) and has demonstrated one of the following (A or B):

1. Measurable progress with the symptoms and behaviors associated with the psychiatric diagnosis or disturbance of mood or behavior is documented not less often than every 4 weeks and all the following are met (1 through 3):
   1. The member and significant others are cooperative with treatment; and
   2. The member and significant others are meeting treatment plan goals; and
   3. The member’s symptoms or disturbances of mood or behavior are at risk for relapse or deterioration without continued intensive in-home behavioral health services; or
2. If progress is not occurring, then the treatment plan is being re-evaluated and amended with goals that are still considered achievable by the appropriately licensed medical professional who conducts the re-assessment.

Not Medically Necessary:

Intensive in-home behavioral health services are considered not medically necessary when the above criteria are not met or when a reassessment performed by an appropriately licensed medical professional has determined either (A or B):

1. No measurable improvement in symptoms or functional impairments has been documented; or
2. The individual’s condition (symptoms or ability to function) has deteriorated and now warrants a more intensive level of care (for example, inpatient or more intensive supervised outpatient behavioral health care).