INTENSIVE FAMILY INTERVENTION (IFI) SERVICES (GEORGIA)

(1)

INTENSIVE FAMILY INTERVENTION (IFI) SERVICES (GEORGIA)

HS-300

Clinical Coverage Guideline page 1 Original Effective Date: 9/17/2015 - Revised: 9/27/2016, 6/1/2017

Care1st Health Plan Arizona, Inc.

Easy Choice Health Plan Harmony Health Plan of Illinois Missouri Care

‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona

OneCare (Care1st Health Plan Arizona, Inc.) Staywell of Florida

WellCare (Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Louisiana, Mississippi, Nebraska, New Jersey, New York, South Carolina, Tennessee, Texas)

WellCare Prescription Insurance

Intensive Family Intervention (IFI) Services (Georgia)

Policy Number: HS-300

Original Effective Date: 9/17/2015 Revised Date(s): 9/27/2016; 6/1/2017

APPLICATION STATEMENT

The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

DISCLAIMER

The Clinical Coverage Guideline (CCG) is intended to supplement certain standard WellCare benefit plans and aid in administering benefits. Federal and state law, contract language, etc. take precedence over the CCG (e.g., Centers for Medicare and Medicaid Services [CMS] National Coverage Determinations [NCDs], Local Coverage Determinations [LCDs] or other published documents). The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this CCG. Additionally, CCGs relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. Providers are responsible for the treatment and recommendations provided to the member. The application of the CCG is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. All links are current at time of approval by the Medical Policy Committee (MPC) and are subject to change prior to the annual review date. Lines of business (LOB) are subject to change without notice; current LOBs can be found at www.wellcare.com. All guidelines can be found at this site as well but selecting the Provider tab, then “Tools” and “Clinical Guidelines”.

BACKGROUND

Intensive Family Intervention (IFI) Services are designed to improve family function, promote reunification, and/or prevent removal of the child from the home. Services are provided using a team approach to the youth within their family structure. The team based approach is used to identify the cause of the youth’s crisis and prevent its occurrence again. Services should be used to help children/adolescents understand and recognize their mental health symptoms. In addition, IFI Services are used to help manage mental illness in children/adolescents. IFI services should also help improve the parent’s/caregiver’s capacity to care for and manage the child’s mental illness. Lastly, linkage to community based services is also provided with IFI services.

(2)

INTENSIVE FAMILY INTERVENTION (IFI) SERVICES (GEORGIA)

HS-300

POSITION STATEMENT Applicable To:

Medicaid – Georgia Exclusions

The following exclusions apply to IFI Services:

 Cannot be offered with CORE services.

 This service may not be provided in group homes, residential facilities, or any environment in which the primary family members or guardians are not present.

 More than one sibling within a family cannot be billed for IFI services.

 The billable activities of IFI do not include a) transportation, b) observation/monitoring, c) tutoring/homework completion, or d) diversionary activities (activities without therapeutic value).

 Members with a primary diagnosis of Autism Spectrum disorder, intellectual disability, traumatic brain injury, or organic mental health disorder are excluded from the IFI program.

Coverage

Intensive Family Intervention Services are considered necessary when the child/youth:

 Is at significant risk of out of home placement; OR

 Has exhausted CORE services; OR

 Has exhausted less intensive outpatient services.

NOTE: IFI services should include crisis intervention, intensive community support with paraprofessionals, individual counseling, and family counseling/ training. Services should be based upon a comprehensive assessment of the youth’s strengths and weaknesses as identified in the treatment plan.

Admission Criteria. The member must meet the following criteria to qualify for IFI Services:

 The member should have a severe emotional and behavioral disorder which results in significant

impairment in daily functioning as measured by the Child and Adolescent Level of Care Utilization System (CALOCUS) score; the score is usually between 20 and 22. The impairment must limit the member’s ability to function in the school, community, and/or family environment; AND

 Member and/or family have severely limited resources to function during an emotional and/or behavioral crisis; AND

 The member’s crisis is not able to be managed in a traditional outpatient treatment program.

In addition, the member could have utilized less intensive outpatient services in the past OR be at risk of out of home placement (e.g., legal system involvement, incarceration) OR at risk for a higher level of care such as acute inpatient or residential level of care.

Continuing Stay Criteria. Same as admission criteria.

Discharge Criteria. The member must meet at least one the following discharge criteria:

 Has met the goals of their individual treatment plan; AND/OR

 Member requires another level of care; AND/OR

 Member’s family desires discharge from the IFI program.

Required Components

 The organization must have a crisis plan available when the youth may require hospitalization or is in crisis.

The organization must be available 24 hours per day / 7 days per week for children and adolescents that may experience a potential crisis.

 The child or adolescent must have access to psychiatric or medical monitoring.

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INTENSIVE FAMILY INTERVENTION (IFI) SERVICES (GEORGIA)

HS-300

 Services must occur in the home or community based settings.

 Each agency must have an Intensive Family Intervention organizational plan that addresses their particular philosophy of treatment. Each agency must practice a particular evidence-based family preservation, resource coordination, crisis intervention and wraparound service models utilized. These may include multi- systemic family therapy, dialectical behavioral therapy (MST, DBT, etc.), as the types of intervention practiced by the agency. The organization must show that individuals are trained in the particular modality.

 At least 60% of services must be provided with the member face to face.

 Over 80% of services must occur in a non-clinic setting.

 Of the total IFI sessions, 50% must occur with the member. When the child is not present, the focus must still be with the child.

CODING

H0036 - Community psychiatric supportive treatment, face-to-face, per 15 minutes

Covered ICD-10-CM Diagnosis Codes – No applicable codes.

Coding information is provided for informational purposes only. The inclusion or omission of a CPT, HCPCS, or ICD-10 code does not imply member coverage or provider reimbursement. Consult the member's benefits that are in place at time of service to determine coverage (or non- coverage) as well as applicable federal / state laws.

REFERENCES

1. Provider manual for community behavioral health providers. Georgia Department of Community Health Web site.

https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20Manuals/tabId/54/Default.aspx. Published July 1, 2015. Accessed May 9, 2017.

MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS

Date Action

6/1/2017, 9/27/2016  Approved by MPC. No changes.

9/17/2015  Approved by MPC. New.