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PCPA Responds to Proposed BHRS Regulations
June 20, 2002

The Pennsylvania Community Providers Association convened a work group to review the 2/25/02 draft of regulations for Behavioral Health Rehabilitation Services (BHRS) proposed by the Department of Public Welfare (DPW). The following comments stem from the discussion at a work group session, as well as written information received from the Conference of Allegheny Providers and numerous other members of PCPA.

The general conclusion is that the proposed regulations codify much the practice that has developed for BHRS services over the past eight years. However, these regulations also propose drastic changes in certain sections that will have a significant impact on the ability of providers to deliver needed services. The following comments reflect the primary concerns of PCPA members with the proposed regulations.

1154.1.1 Policy

The policy statement indicates that BHRS services are available for "children who present with social, emotional or behavioral issues that result in impairment..." Provider agencies currently report denials of service requests for services related to social and life skills issues. Clarification appears to be needed.

1154.1.2 Definitions

The proposed regulations introduce the concept of a "primary clinician" to the provision of Behavioral Health Rehabilitation Services. There are numerous references to this concept, but no clear definition. There is need for elaboration on the definition of primary clinician, responsibilities of this function, who can serve in this role, and reimbursement for performing the functions of primary clinician.

We recommend that the regulations be revised to indicate that Mobile Therapists, as well as other qualified clinicians, can function in the role of the "primary clinician." In addition, we recommend that time spent by the primary clinicians in the development and updating of the treatment plan be designated a covered service.

1154.11 Types of Services

The proposed regulations do not appear to appreciate the critical functions of the Mobile Therapist (or others acting as the Primary Clinician) in bringing various parties together and communicating to ensure a comprehensive treatment approach. Therefore, we recommend that there be changes to the Mobile Therapy covered services section. The first covered service should be amended to read "Assessment and face-to-face psychotherapy with the child." The third service should be amended to read "Data gathering, observation and assessment for the development of a treatment and behavioral plan." We recommend that two new services be added. Writing of a treatment plan is a critical component of the system of care approach. Likewise, there must be recognition of the importance of working with school personnel, the family, and others involved with the child receiving Mobile Therapy.

The section on covered services for Behavior Specialist Consultant requires a definition for direct services. In addition, a new service should be added "Observation, assessment and development of the treatment plan."

1154.12 Noncovered Services

Section (6) should be amended to read "Services not identified in the child's treatment plan except in situations requiring immediate therapeutic intervention until treatment plan modifications can be implemented."

In Section (8), there needs to be recognition of the critical function of the Mobile Therapists and Behavioral Specialist Consultants in the treatment planning process. Part (a) should be amended to read "assessment, observation, collateral contacts, and gathering data for the development of a treatment and/or behavioral plan. In addition, development of the treatment plan must be recognized as a covered service.

Section (16) identifies respite care as a noncovered service. We understand that respite may not be characterized as a medically necessary service, but experience shows that respite can be an effective service in enabling the child to remain with the family. Services such as crisis stabilization and therapeutic stabilization can be especially effective. It is currently possible to request special consideration through the service description process. However, respite works best when agencies have specially trained respite providers and there are options for families. The individualized exception process does not facilitate this. We recommend that there be attention to innovative approaches to respite as a part of behavioral health rehabilitation.

1154.41 Provider Participation

Section (a) references participation requirements in Chapter 1101. This is a broad Chapter that contains items not related to BHRS providers. We recommend that section 1154.41 be made more specific to BHRS providers.

Section (a) (3) lists three types of licensed or certified providers. We recommend that Drug and Alcohol providers be added.

Section (b) limits subcontracting to individuals or agencies not enrolled in the MA program. We urge reconsideration of this requirement as it curtails innovative and effective collaboration, which is a centerpiece of the system of care for children.

1154.42 Ongoing Responsibilities of Providers

Section (b)(6) requires providers to include, in the medical record, "Such other information and forms required by the Department, as specified in MA Bulletins or the provider handbook." Section1154.42 should identify the specific information and forms that pertain to the medical records of BHRS services.

1154.43 Staff Qualifications

Section (b) proposes a substantially higher standard for Mobile Therapist (clinical practicum and one year of paid experience) than DPW's definition of a "mental health professional" which is the current Mobile Therapist requirement. No rationale is given for why Mobile Therapists have to comply with a higher standard than outpatient therapists or Family Based Mental Health Therapists (for which there is typically a higher reimbursement). This appears excessive and may not be necessary to ensure clinical expertise. It will, however, significantly limit the pool of prospective applicants. The proposed new qualification standards will also affect the pool of those eligible to provide supervision. While the proposed regulations allow for "grandfathering" of current Mobile Therapists, the rate of turnover typical in this position across the Commonwealth suggests that within a year or two there will be a severe shortage of individuals qualified to fill these positions, especially in rural areas.

We recommend that the qualifications and requirements for Mobile Therapists remain as they are currently (the DPW definition of a "mental health professional"), which is consistent with the qualifications required for such a clinician within other levels of care in the Commonwealth.

Section (3) (iii) requires 20 hours of training for full time or part time Mobile Therapists. This amount of training was not factored into the rate of reimbursement for this service. Furthermore, this requirement will create additional barriers for provider agencies to recruit and retain part-time staff.

Section (d), requirements for Behavior Specialist Consultants (BSC), will create significant service problems. There are a limited number of mobile therapists who have sufficient behavioral training, which has led providers to utilize Behavioral Specialist Consultants. The proposed draft regulations severely limit the pool of qualified individuals to serve as Behavioral Specialist Consultants. In addition, no "grandfathering" of current BSCs is allowed for in the proposed regulations. There will be a sudden and dramatic reduction of current BSCs immediately upon implementation of the regulations. This will create unacceptable continuity of care issues for children and their families.

We recommend that the qualifications and requirements for all BSCs be broadened, and that "grandfathering" of current BSCs be allowed.

The proposed regulations emphasize ABA-based models for the treatment of children with Autism Spectrum Disorders over other recognized and well-researched models. We recommend that these other models be identified in these regulations.

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