Point32 In-Home Behavioral Services (IHBS): Massachusetts Products Form

In-Home Behavioral Services (IHBS): Massachusetts Products

Behavioral services are delivered by one or more members of a team consisting of professional and paraprofessional staff, offering a combination of medically necessary behavior management therapy and behavior management monitoring.

Coverage for services is available to children and adolescents that meet the following medical necessity criteria until the Member’s 19th birthday. The Plan will continue coverage for services for Members aged 19 and beyond when services are medically necessary and part of an ongoing treatment plan.

Behavior Management Therapy:

This service includes a behavioral assessment (including observing the youth’s behavior, antecedents of behaviors, and identification of motivators), development of a highly specific behavior plan; supervision and coordination of interventions; and training other interveners to address specific behavioral objectives or performance goals. This service is designed to treat challenging behaviors that interfere with the youth’s successful functioning. The behavior management therapist develops specific behavioral objectives and interventions that are designed to diminish, extinguish, or improve specific behaviors related to the youth’s behavioral health condition(s) and which are incorporated into the behavior plan and the risk management/safety plan.

Behavior Management Monitoring:

This service includes implementation of the behavior plan, monitoring the youth’s behavior, reinforcing implementation of the behavior plan by the parent(s)/guardian(s)/caregiver(s), and reporting to the behavior management therapist on implementation of the behavior plan and progress toward behavioral objectives or performance goals. Phone contact and consultation may be provided as part of the intervention. For youth engaged in Intensive Care Coordination (ICC), the behavior plan is designed to achieve a goal(s) identified in the youth’s Individual Care Plan (ICP). The Care Planning Team (CPT) works closely with the youth, parent/guardian/caregiver and/or other individual(s) identified by the family to support adherence to the behavior plan and to sustain the gains made.

Clinical Guideline Coverage Criteria

Admission Criteria

The Plan considers initial in-home behavioral services as reasonable and medically necessary when ALL of the following criteria are met:

1. A comprehensive behavioral health assessment indicates that the youth’s clinical condition warrants this service in order to diminish, extinguish, or improve specific behaviors related to the youth’s behavioral health condition(s). If the Member has MassHealth as a secondary insurance and is being referred to services by a provider who is paid through the Member’s primary insurance, the provider must conduct a comprehensive behavioral health assessment;
2. Less intensive behavioral interventions have not been successful in reducing or eliminating the problem behavior(s) or increasing or maintaining desirable behavior(s); and
3. Clinical evaluation suggests that the youth’s clinical condition, level of functioning, and intensity of need require the establishment of a specific structure, and the establishment of positive behavioral supports to be applied consistently across home and school settings; and warrant this level of care to successfully support him/her in the home and community; and
4. Required consent is obtained; and
5. The youth is currently engaged in outpatient services, In-Home Therapy or ICC and the provider or ICC CPT, determine that In-Home Behavioral Services are needed in order to facilitate the attainment of a goal or objective identified in the treatment plan or ICP that address specific behavioral objectives or performance goals designed to treat challenging behaviors that interfere with the youth’s successful functioning; and

Continuation Criteria

The Plan considers continuation of in-home behavioral services as reasonable and medically necessary when ALL of the following criteria are met:

1. The youth's clinical condition(s) continues to warrant In-Home Behavioral Services in order to maintain him/her in the community and continue progress toward goals established in the behavior plan; and
2. The youth is actively participating in the plan of care and treatment to the extent possible consistent with his/her condition; and
3. With consent, the parent/guardian/caregiver, and/or natural supports are actively involved in the treatment as required by the behavior plan, or there are active efforts being made and documented to involve them.

Discharge Criteria

The Plan considers continuation of in-home behavioral services as not reasonable and medically necessary when ANY of the following criteria are met:

1. The youth no longer meets admission criteria for this level of care, or meets criteria for a less or more intensive level of care; or
2. The youth's behavior plan goals and objectives have been substantially met and continued services are not necessary to prevent the worsening of the youth's behavior; or
3. The youth and/or parent/guardian/caregiver are not engaged in treatment. The lack of engagement is of such a degree that treatment at this level of care becomes ineffective or unsafe, despite multiple, documented attempts to address engagement issues; or
4. The youth is not making progress toward goals and objectives in the behavior plan, and there is no reasonable expectation of progress at this level of care, nor is it required to maintain the current level of functioning; or
5. Consent for treatment is withdrawn.

*Please note that Psychosocial, Occupational, and Cultural and Linguistic factors may change the risk assessment and should be considered when making level-of-care decisions.

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In-Home Behavioral Services (IHBS): Massachusetts Products

Limitations

Coverage for services is available to children and adolescents that meet the foregoing medical necessity criteria until the Member’s 19th birthday. The Plan will continue coverage for services for Members age 19 and beyond when services are medically necessary and part of an ongoing treatment plan. The Plan considers in-home behavioral services as not reasonable or medically necessary if ANY of the following criteria are met:

1. The environment in which the service takes place presents a serious safety risk to the behavior management therapist or monitor, alternative community settings are not likely to ameliorate the risk and no other safe venue is available or appropriate for this service; or
2. The youth is at imminent risk to harm self or others, or sufficient impairment exists that requires a more intensive level of care beyond a community-based intervention; or
3. The youth has medical conditions or impairments that would prevent beneficial utilization of services.
4. The youth is in a hospital, skilled nursing facility psychiatric residential treatment facility or other residential setting at the time of referral and is not ready for discharge to a family home environment or community setting with community-based supports.