Medical Policy for Maternal and Child Health

CHAPTER 4 00 M EDICAL POLICY FOR MATERNAL AND CHILD HEALTH POLICY 450 OUT-OF-STATE PLACEMEN TS FOR A CHILD OR YOUNG ADULT

400 OUT - - OF - - STATE PLACEMENTS FOR CHILDREN OR YOUNG ADULTS FOR BEHAVIORAL HEALTH TREATMENT1

INITIAL EFFECTIVE DATE: 07/01/20162

Purpose

The purpose of this Policy is to provide criteria and procedures for Contractors3 and Tribal Regional Behavioral Health Authorities (TRBHAs) and their providers in the event that an out-of-state placement is clinically necessary and supported by the Child and Family Team (CFT) or Adult Recovery Team (ART).

At times,On occassion Iit may be necessary to consider an out-of-state placement for a child or young adult to meet the personmember’s4 unique circumstances or clinical needs. The following factors may lead a personmember’s Child and Family Team (CFT) or Adult Recovery Team (ART) to consider the temporary out-of-state placement: of a child or young adult:5.

1. A child or young adultThe member requires6 needs specialized programming not currently available in Arizona to effectively treat a specified behavioral health condition,

2. An out-of-state placement’s approach to treatment incorporates and supports the child or young adult’s unique cultural heritage of the member7,

3. A lack of current in-state bed capacity, and/or

4. Geographical proximity encourages support and facilitates family involvement in the personmember’s treatment.

1 DBHS Policy 408, Out- of -State Placement for Children and Young Adults reviewed to merge appropriate provisions within ACOM Policy 450. 2 Arizona Laws 2015, Chapter 19, Section 9 (SB 1480) enacts that from and after June 30, 2016, the provision of behavioral health services under DBHS in the Department of Health Services is transferred to and shall be administered by AHCCCS. 3 Included all populations for clarification. 4 Revised throughtout this document to reflect current practice and provide clarification. 5 Repetative, the title of the Policy states demographic. 6 Clarification 7 Clarification ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 450-1 AHCCCS MEDICAL POLICY MANUAL The purpose of this Policy is to provide criteria and procedures for Tribal Behavioral Health Authorities (TRBHAs), Regional Behavioral Health Authorities (RBHAs), Children’s Rehabilitative Service (CRS) and their providers in the event that an out-of- state placement is clinically necessary and supported by the CFT or ART.8

The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS)AHCCCS expects that decisions to place children or young adults in out- of-state placements for behavioral health care and treatment are examined closely and made after the CFT or ART have reviewed all other in-state options. Other options may include single case agreements with in-state providers or the development of an Individual Service Plan (ISP) that incorporates a combination of support services and clinical interventions.

In the event that an out-of-state placement is clinically necessary and supported by the CFT or ART, Tribal Behavioral Health Authorities (TRBHAs), Regional Behavioral Health Authorities (RBHAs), Children’s Rehabilitative Service (CRS) Tribal and Regional Behavioral Health Authorities (T/RBHAs) and their providers must follow the steps and procedures outlined in this section. Services provided out-of-state must meet the same requirements as those rendered in-state. T/RBHAs, RBHAs, and CRS must also ensure that out-of-state providers follow all AHCCCS reporting requirements, as well as ADHS/DBHS policies and procedures, including appointment standards and timelines specified in Policy 102, Appointment Standards and Timeliness of ServiceACOM Policy 417, Appointment Availability, Monitoring and Reporting.9

POLICY

A. GENERAL REQUIREMENTS

Decisions to place members in out-of-state placements for behavioral health care and treatment shall be examined closely and made after the CFT or ART have reviewed all other in-state options. Other options may include single case agreements with in- state providers or the development of an Individual Service Plan (ISP) that incorporates a combination of support services and clinical interventions.

Services provided out-of-state must meet the same requirements as those rendered in- state. Contractors RBHAs, and CRS10 must also ensure that out-of-state providers follow all AHCCCS reporting requirements, policies and procedures, including appointment standards and timelines specified in ACOM Policy 417., Appointment Availability, Monitoring and Reporting.

Out of state placement providers shall coordinate with the Contractors and TRBHAs to provide required updates.

When the TRBHAs, RBHAs, and CRS T/RBHA isare considering an out-of-state placement for a child or young adult, the following conditions apply:

8 Moved this section to the beginning of Purpose. 9 Moved to A. 10 Clarification and TRBHAS are covered in IGA. CHAPTER 4 00 M EDICAL POLICY FOR MATERNAL AND CHILD HEALTH POLICY 450 OUT-OF-STATE PLACEMEN TS FOR A CHILD OR YOUNG ADULT

The following conditionscircumstances must exist in order to consider apply for consideration of an out-of-state out of state placement for a member11 :

1. The CFT or ART will consider explore12 all applicable and available in- state services and placement options and13, a.a. determine Determine that the services do not adequately meet the specific needs of the personmember, or a.b. In-state facilities decline to accept the member.14

2. The personmember’s family/guardian is in agreement with the out-of-state placement (for minors and personmembers between 18 and under 21 years of age under guardianship),

3. The out-of-state placement is registered as an AHCCCS provider,

4. Prior to placement, the Contractor and TRBHA shall ensure the member has access to non-emergent medical needs by an AHCCCS registered provider, 15

5. The out-of-state placement meets the Arizona Department of Education Academic Standards, and

6. A plan for the provision of non-emergency medical care must be established.

B. CONDITIONS BEFORE A REFERRAL FOR OUT-OF-STATE PLACEMENT IS MADE

The Contractors and TRBHAs shall ensure that16 Ddocumentation in the clinical record must indicates the following conditions have been met before a referral for an out-of-state placement is made:

1. All less restrictive, clinically appropriate approaches have either been provided or considered by the CFT or ART and found not to meet the personmember’s needs.,

2. A minimum of three in-state facilities have declined to accept the personmember.,

11 Clarification 12 Clarification 13 Clarification 14 Clarification 15 Clarification 16 Clarification ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 450-1 AHCCCS MEDICAL POLICY MANUAL 3. The CFT or ART has been involved in the service planning process and is in agreement with the out-of-state placement.,

4. The CFT or ART has documented how they will remain active and involved in service planning once the out-of-state placement has occurred.,

5. An ISP has been developed.,

6. All applicable prior authorization requirements have been met.,

7. The Arizona Department of Education has been consulted to ensure that the educational program in the out-of-state placement meets the Arizona Department of Education Academic Standards and the specific educational needs of the personmember.,

8. Coordination has occurred with all other state agencies involved with the personmember, including notification to the Medical Director of the Division of Developmental Disabilities (DDD) when the memberindividual is enrolled with DDD and the Medical Director of Tthe Comprehensive Medical and Dental Plan (CMDP) when the memberindividual is enrolled with CMDP.,

9. Coordination has occurred between Tthe personmember’s primary care provider and the AHCCCS Acute Health Plan17 entity responsible for the provision of physical health to develop a plan for the provision of any necessaryhave been contacted and a plan for the provision of any necessary, non-emergency medical care. has been established and is included in the comprehensive clinical record. The Contractors and TRBHAss, RBHAs, and CRST/RBHAs must provide clarification in policies and procedures clarify for providers, in their policies and procedures, that shall identifyies who is responsible for this coordinationthis activity.18 All providers shall be registered AHCCCS providers., and

10. In the event that a personmember has been placed out-of-state due to an emergency situation or unforeseen event, the TRBHAs, RBHAs, and CRST/RBHA must address all applicable above conditions as soon as notification of the out-of-state placement is received19.

C. INDIVIDUAL SERVICE PLAN (ISP)

For a personmember placed out-of-state, the ISP developed by the CFT or ART must require that:

1. Discharge planning is initiated at the time of referral admission 20 or notification of admission, including:

17 Revised to reflect that this is not always an acute care plan. 18 Clarification 19 Balance Budget Act states emergency services do not require prior authorization. 20 Clarification CHAPTER 4 00 M EDICAL POLICY FOR MATERNAL AND CHILD HEALTH POLICY 450 OUT-OF-STATE PLACEMEN TS FOR A CHILD OR YOUNG ADULT

A. The measurable treatment goals being addressed by the out-of-state placement and the criteria necessary for discharge back to in-state services., B. The possible or proposed in-state residence where the personmember will be returning., C. The recommended services and supports required once the personmember returns from the out-of-state placement., D. What needs to be addressed or arranged to accept the personmember for subsequent in-state placement that will meet the personmember’s needs, 21 E. How effective strategies implemented in the out-of-state placement will be transferred to the personmembers’ subsequent in-state placement., F. The actions necessary to integrate the personmember into family and community life upon discharge., and G. The CFT or ART actively reviews the memberperson’s progress with the clinical staffings occurring at least every 30 days. 22 NOTE: Clinical staffings must include the staff of the out-of-state facility. Inclusion of the out of state failiccility staff in clinical staffings. 23

2. When appropriate, Tthe personmember’s family/guardian is involved throughout the duration of the placement. This may include family counseling in personperson or by teleconference or video-conference.

A. The CFT or ART must ensure that essential and necessary health care services are provided, and 24

Home passes are allowed as clinically appropriate and in accordance with the AHCCCS BEHAVIORAL HEALTH COVERED SERVICES GUIDE . AHCCCS BEHAVIORAL HEALTH COVERED SERVICES GUIDE . For youth in Department of Child Safety (DCS)Child Protective Services (CPS) custody, approval of home passes must beare determined only in close in collaboration with DCSCPS. 25

3. The personmember’s needs, strengths, and cultural considerations have been addressed.

D. INITIAL NOTIFICATION TO ADHS/DBHS OFFICE OF AHCCCS MEDICAL MANAGEMENT (MM) 26

1. The Contractors and TRBHAs, RBHA, and CRS are required to notify AHCCCS MM usingby emailing a completed the AHCCCS Out-of-State Placement Form

21 Redundant. Information is detailed in this section. 22 Clarification and conformity to current AHCCCS practice. 23 Information not needed. 24 Redundant. Information is in section B.9. 25 This section revision for clarification and conformity. 26 MM will be responsible for this function due to merger. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 450-1 AHCCCS MEDICAL POLICY MANUAL (Appendix DExhibit 450-1 27 ) to AHCCCS Medical Management ([email protected]) under the following circumstances: A. Immediately upon notification or discovery that a member has been emergently admitted to a out-of-state behavioral health hospital B. Upon notification or discovery that a member is in an out-of-state out of state behavioral health hospital or residential treatement facility. c. Prior to a referral for and out of state placement (Approval from AHCCCS of all planned out of state placments must be obtained prior to making a referral for out-of-state placement, in accordance with the criteria outlined in this subsection B within this Policy). D. Prior to placement in an out -of -state placement.

2. Prior authorization by the TRBHA, RBHA and CRS is required for all out- of- state placements28. 3. 4. Prior approval from AHCCCS of all planned out of state placments must be obtained prior to making a referral for out-of-state placement, in accordance with the criteria outlined in this Policy. Providers may assist with supplying information and with providing copies of supporting clinical documentation as required by the AHCCCS Out-of-State Placement Form (Appendix D). 5.

The TRBHAs, RBHAs, and CRS T/RBHAs are required to notify ADHS/DBHS Office ofAHCCCS Medical Management immediately upon notification that a member has been emergently placed in an out-of-state Behavioral Health Hospital Facility, using the AHCCCS Oout-oOf-Sstate pPlacement fForm (Appendix D) found in the Bureau of Quality and Integration (BQ&I) Specifications Manual.29

THE TRBHAS, RBHAS, AND CRS T/RBHAS ARE REQUIRED TO NOTIFY ADHS/DBHS OFFICE OF MEDICAL MANAGEMENT MM PRIOR TO A REFERRAL FOR OUT-OF-STATE PLACEMENT AND UPON DISCOVERING THAT A T/RBHA ENROLLEE MEMBER IS IN AN OUT-OF- STATE PLACEMENT USING THE OUT-OF- S STATE PLACEMENT FORM BQ & I SPECIFICATIONS MANUAL ATTACHMENT, OUTOF-STATE PLACEMENT. PRIOR AUTHORIZATION MUST BE OBTAINED PRIOR TO MAKING A REFERRAL FOR OUT-OF- STATE PLACEMENT, IN ACCORDANCE WITH T/RBHA THE CRITERIA. THE TRBHAS, RBHAS, AND CRS T/RBHAS MAY ASK THAT PROVIDERS ASSIST WITH SUPPLYING THE INFORMATION REQUIRED ON THE FORM AND WITH PROVIDING COPIES OF SUPPORTING CLINICAL DOCUMENTATION .

PRIOR TO PLACING THE CHILD OR YOUNG ADULT MEMBER IN AN OUT-OF-STATE RESIDENTIAL TREATMENT FACILITY OR UPON DISCOVERING THAT A T/RBHA ENROLLEE MEMBER HAS BEEN ADMITTED TO AN OUT-OF-STATE BEHAVIORAL HEALTH HOSPITAL , T HE TRBHAs, RBHAs, and CRS or T/RBHA OR BEHAVIORAL HEALTH PROVIDER MUST COMPLETE BQ & I SPECIFICATIONS MANUAL ATTACHMENT APPENDIX D , AHCCCS OUT-OF-STATE PLACEMENT FORM AND SUBMIT VIA SECURE E-MAIL AN ELECTRONIC COPY TO ADHS/DBHS OFFICE OF AHCCCS MEDICAL MANAGEMENT

27 Attachment originally noted as Appendix D, changed to add as an Exhibit to this policy; clarification. 28 Clarification 29 Removed, duplicative. CHAPTER 4 00 M EDICAL POLICY FOR MATERNAL AND CHILD HEALTH POLICY 450 OUT-OF-STATE PLACEMEN TS FOR A CHILD OR YOUNG ADULT

( [email protected] [email protected]), VIA SECURE E-MAIL, FOR APPROVAL OF PLANNED OUT-OF-STATE PLACEMENTS OR NOTIFICATION OF EMERGENCY BEHAVIORAL HEALTH HOSPITALIZATIONS. COMPLETED FORMS MUST BE SUBMITTED IN ELECTRONIC FORMAT ONLY .

6. THE TRBHAS, RBHAS, AND CRS RBHA MUST DEVELOP AND MAKE AVAILABLE POLICIES AND PROCEDURES THAT CLEARLY INDICATE THAT THE RBHA OR THE BEHAVIORAL HEALTH PROVIDER WILL SUBMIT THE REQUIRED REPORTING FORM TO ADHS/DBHS OFFICE OF MEDICAL MANAGEMENT MM . 30

7. ADHS/DBHSMM will review the information on the AHCCCS Out-of-State Placement Form (Exhibit 450-1 31 ) Out-of-State Placement Form oin the AHCCCS Out-of-State Placement fForm and render an approval within 24 to XXX72 hours1-3 business days 32 .and Iif the information is incorrect or incomplete, the form will be sent back returned to the T/RBHA’s for correction. The corrected form must be resubmitted and reprocessed for approval upon resubmission. . 8. The TRBHAs, RBHAs, and CRS must develop and make available policies and procedures that comply with the requirements in this Policy.

E. REQUIRED UPDATES TO ADHS/DBHS OFFICE OF AHCCCS MEDICAL MANAGEMENT

1. 1. In addition to providing initial notification, the Contractors and TRBHA S S , RBHAS, AN D CRS T/RBHA IS are required to submit electronic updates to ADHS/DBHS Office of Medical ManagementAHCCCS MM regarding the personmember’s progress status in meeting the identified criteria for discharge from the out-of-state placement. The update shall include input from providers involved in the provision of service to the members. every thirty (30) calendar days, or within 48 hours after notification of discharge from the out-of-state facility. Thirty (30) days refers to calendar days and 48 hours refers to business days with business days excluding weekends and holidays. If a thirty (30) day update date falls on a weekend or holiday, it will be submitted on the next business day. To adhere to this requirement, TRBHAs, RBHAs, and CRS T/RBHAs must use the BQ&I Specifications ManualAppendix D Attachment, Out-of-State Placement Form. TRBHAs, RBHAs, and CRST/RBHAs may ask that providers assist with providing the information required on the form. 33

30 This information is related to how the Contractor will receive the information from the Provider and is not needed here. 31 Attachment originally noted as Appendix D, changed to add as an Exhibit to this policy; clarification. 32 Conformity to current practice. 33 This section has been revised for clarification. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 450-1 AHCCCS MEDICAL POLICY MANUAL 2.

2. The statusprogress update, using the on amust be n updated AHCCCS Out-of-State Placement Form (Exhibit 450-1 34 )Out-of-State Placement Form, must be emailed to AHCCCS MM ( [email protected] [email protected] OV ) submitted via secure email using the Out–of-State Placement Form (Appendix D)Once completed, TRBHAs, RBHAs, and CRS T/RBHAs must submit the form via secure e-mail in electronic format to ADHS/DBHS Office ofAHCCCS Medical ManagementMM via secure e-mail to every thirty (30) 30 days that the personmember continues to remains in the out-of-state placement. The thirty (30) day update timelines will shall be based upon the date of DBHS AHCCCS approval of the out-of-state placement. If a 30 day update date falls on a weekend or holiday, it must be submitted on the next business day. 35

3. TRBHAs, RBHAs, and CRS T/RBHAs must utilize and make available the reporting forms related to the thirty (30) day update in their policies and procedures as described in this policy. 36

4. REQUIRED REPORTING OF AN OUT-OF - STATE PROVIDER

All out-of-state providers are required to meet the reporting requirements of all incidences of injury/accidents, abuse, neglect, exploitation, healthcare acquired conditions, injuries from seclusion/restraint implementations as described in AMPM Policy 1702, Reporting of Seclusion, Restraint and Emergency Safety Response 960, Tracking and Trending of Member and Provider Issues960Tracking and Trending of Member and Provider Issues.37

REFERENCES 38

34 Attachment originally noted as Appendix D, changed to add as an Exhibit to this policy; clarification. 35 This section has been revised for clarification and conformity to current practice. 36 Repetative information; clarification. 37 Clarification 38 Information not needed, referenced in Policy.