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(1) The reimbursement rate for the therapeutic and rehabilitative portion of TGH or TGH with extraordinary needs aide (ENA) services is the lesser of (1)(a) or (b):

(a) the amount specified in the department's Medicaid Mental Health Fee Schedule as adopted in ARM 37.97.901; or

(b) the provider's usual and customary charges.

(2) The therapeutic services provided by the lead clinical staff (LCS) and the program manager (PM) are "therapy" and "therapeutic intervention" services defined as:

(a) "Therapy " means the provision of psychotherapy and rehabilitative services provided by the LCS acting within the scope of the professional's license or same services provided by an in-training mental health professional in a TGH. These services include a combination of supportive interactions, cognitive therapy, interactive psychotherapy, and behavior modification techniques which are used to induce therapeutic change for youth in TGH. (Interactive psychotherapy means using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication.)

(b) "Therapeutic intervention" means interventions provided by the LCS or the PM under the supervision of the LCS to provide youth with activities and opportunities to improve social, emotional, and/or behavioral skill development and reduce symptoms of the youth's serious emotional disturbance. Interventions include implementing behavior modification techniques and offering psycho-educational groups and activities. Interventions may be provided to the youth individually, in a group setting or with the youth and family.

(3) The purpose of the therapeutic services in (2) is:

(a) to reduce the impairment of the youth's mental disability and to improve the youth's functional level;

(b) to alleviate the emotional disturbances;

(c) to reverse or change maladaptive patterns of behavior; and

(d) to encourage personal growth and development.

(4) TGHs are reimbursed a daily or patient day rate.

(a) "Patient day" means a whole 24-hour period that a youth is present and receiving TGH services. Even though a youth may not be present for a whole 24-hour period, the day of admission is a patient day. The day of discharge is not a patient day.

(5) TGH providers must use the procedure codes designated by the department, per the fee schedule in (1)(a) to be reimbursed for TGH, TGH with ENA, or TGH therapeutic home visit (THV) services.

(6) Medicaid will not reimburse for room, board, maintenance, or any other nontherapeutic component of TGH services.

(7) Reimbursement will be made to a provider for reserving a TGH bed while the youth is temporarily absent for a THV. A THV is an opportunity to assess the youth's ability to successfully transition to a less restrictive level of care. For reimbursement the following criteria must be met:

(a) the youth's treatment plan must document the medical need for a THV as part of a therapeutic plan to transition the youth to a less restrictive level of care;

(b) the TGH provider clearly documents staff contact and youth achievements or regressions during and following the THV; and

(c) the youth is absent from the provider's facility for no more than three patient days per THV, with a maximum of 14 THV patient days per state fiscal year, unless additional days are prior-authorized by the department.

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, MCA; NEW, 2011 MAR p. 49, Eff. 1/15/11.

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