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DPW Reinforces Medical Necessity of BHRS Services
March 8, 2001

The Office of Legal Counsel, Department of Public Welfare, provided a copy of a letter sent from the Department to all county mental health/mental retardation programs in the Commonwealth, in accordance with an informal "side letter" agreement as part of the Kirk T. vs. Houstoun lawsuit. The text of that letter appears below. Member questions regarding behavioral health rehabilitation services (BHRS) issues can be directed to Lisa Lowrie at the Association.

January 25, 2001

Dear County MH/MR Administrator:

The purpose of this letter is to reinforce the Department of Public Welfare's policy regarding medically necessary behavioral health rehabilitation services provided to children and adolescents as well as the role of the county mental health/mental retardation ("MH/MR") program in the provision of these services.

The Department's Medical Assistance Program provides coverage for medically necessary behavioral health rehabilitation services rendered to eligible Medical Assistance ("MA") recipients under twenty-one years of age. An individual under the age of twenty-one with a mental illness, a severe emotional disturbance, or a behavioral issue associated with another condition such as mental retardation is eligible for medically necessary behavioral health rehabilitation services, whether or not the service is listed in the MA Program Fee Schedule.

The goal of behavioral health rehabilitation services is to maintain the child at home or as close to home and community as possible in the most normalizing and age appropriate setting in order to avoid unnecessarily restrictive or otherwise inappropriate placements. In accordance with Department policy, these services may be provided in a variety of treatment settings, including the child's own home, school, and community. The goal of treatment is to improve a child's functioning to a point where the service is no longer needed. In some cases, however, services may be needed to maintain a child's level of functioning and prevent decompensation. The actual intensity of and length of time for which services are delivered to child are based solely on the child's medical need for the services.

It is the role of the Department, or the appropriate behavioral health managed care organization ("MCOs"), not the county, to determine the medical necessity of behavioral health rehabilitation services. When such services are prescribed, it is the role of the members of the Interagency Service Planning Team, including county MH/MR staff, to help develop a plan to meet the child's and family's needs. The role of county staff members is especially important in exploring and developing other community resources that may assist the family in meeting the child's individual needs. These efforts must, however, be undertaken consistent with Department policy regarding the provision of behavioral health rehabilitation services.

If county MH/MR staff members have a concern regarding the prescription or provision of any behavioral health rehabilitation service, they should contact the Department or MCO staff. If the services require prior authorization, the concern should be stated in writing and submitted with the request for service. The Department, or MCO, will review all documentation submitted when making a determination of medical necessity for the requested service. The county may not overtly or implicitly "deny" or otherwise inappropriately influence the prescription or provision of services in any setting, or change or limit services in any manner.

If you should have any concerns or questions, please feel free to contact Donald Yearsley at 717-772-6147 or Jim Myers at 717-772-7928.

Sincerely,

Suzanne Love, Director
Bureau of Policy, Budget and Planning
Office of Medical Assistance Programs

Jerry Kopelman, Director
Bureau of Policy and Program Development
Office of Mental Health and Substance Abuse Services

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