CurrentAgency for Health Care AdministrationPolicy N/A

Behavioral Health Community Support Services Coverage Policy

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This policy governs coverage of behavioral health community support services for eligible Florida Medicaid recipients, including recipients enrolled in Florida Medicaid managed care plans. It establishes recipient eligibility, provider obligations, coverage criteria, copayment requirements, and coordination with other Florida Medicaid policies.

Policy Summary

PayerAgency for Health Care Administration

PolicyBehavioral Health Community Support Services Coverage Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify each recipient's Florida Medicaid eligibility every time a service is rendered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1,920 unitsCombined annual service limit

12Maximum group size

16 yearsClubhouse minimum age

4Qualifying symptom or impairment categories

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CurrentAgency for Health Care AdministrationPolicy N/A

Behavioral Health Community Support Services Coverage Policy

Customize your policy alerts

Sign up for all Agency for Health Care Administration policy alerts

Know when Agency for Health Care Administration releases new policies or updates existing guidance.

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Policy Summary

PayerAgency for Health Care Administration

PolicyBehavioral Health Community Support Services Coverage Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify each recipient's Florida Medicaid eligibility every time a service is rendered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1,920 unitsCombined annual service limit

12Maximum group size

16 yearsClubhouse minimum age

4Qualifying symptom or impairment categories

Service-specific authorization criteria

Coverage Criteria

Eligible recipient criteria

Covered for eligible recipients when all applicable criteria are met.

Recipient and clinical eligibility

Program eligibility: The individual is enrolled in the Florida Medicaid program on the date of service.
Clinical eligibility
- Qualifying symptom or impairment: The recipient exhibits one or more of the following: psychiatric symptoms; behavioral or cognitive symptoms; addictive behavior; or a clinical condition severe enough to cause significant impairment in day-to-day functioning.
  At least one listed symptom or condition must be present.

Eligible recipient

Eligible recipients must have a mental health diagnosis and exhibit at least one qualifying symptom or condition.

Recipient eligibility

Qualifying presentation: The recipient exhibits psychiatric symptoms; behavioral or cognitive symptoms; addictive behavior; or a clinical condition severe enough to cause significant impairment in day-to-day functioning.

General coverage

Covered services must meet all of the following criteria.

General coverage criteria: The service is medically necessary; does not duplicate another service; and meets the criteria specified in this policy.

Psychosocial rehabilitation services

Psychosocial rehabilitation services are covered when they provide rehabilitative support addressing functional and social needs.

Psychosocial rehabilitation: Services restore or support skills and abilities necessary for independent living, concentrate on ameliorating symptoms and restoring functional capabilities, and assist with eliminating or compensating for functional deficits and interpersonal or environmental barriers or restoring social skills for independent living and life management.Group size cannot exceed 12

Services may be provided in a facility, home, or community setting and may include daily living, medication-use, housing, vocational, employment, social-support, and network-enhancement activities.

Clubhouse services

Clubhouse services are covered when delivered as structured, rehabilitative, community-based group services.

Clubhouse services: Services use behavioral, cognitive, or supportive interventions to improve the recipient's ability to establish and maintain social relationships and achieve occupational or educational goals; address functional, interpersonal, and environmental barriers; restore social skills for independent living and life management; and facilitate cognitive and socialization skills needed for work and independence.Recipient must be at least 16 years old; group size cannot exceed 12

Services must be delivered in a group setting and use a wellness model to restore independent living skills.

Early and Periodic Screening, Diagnosis, and Treatment

For recipients under age 21, additional services may be approved when medically necessary under EPSDT.

EPSDT coverage: The recipient is under 21 years of age and the service is medically necessary to correct or ameliorate a defect, condition, or physical or mental illness.Under 21 years

Coverage may exceed the services described in this policy or the associated fee schedule; applicable services include diagnostic services, treatment, equipment, supplies, and other measures described in section 1905(a) of the Social Security Act.

Services are not covered when they fail medical necessity requirements in section 1.0, fail the recipient eligibility requirements in section 2.0, or unnecessarily duplicate another provider’s service. The benefit also excludes babysitting or child care, case management, services provided on the day of admission into the Statewide Inpatient Psychiatric Program, services to individuals residing in an institution for mental diseases or to institutionalized individuals as defined in 42 CFR 435.1009, transportation, and travel time.

Services that do not meet the medical necessity criteria listed in section 1.0 are not covered.

Coding and Service Limits

Claim Typemixed

837P	Professional claim
CMS-1500	Professional claim form

Combined Annual Service Limit

Annual limitUp to 1,920 units per recipient per fiscal year

Services includedPsychosocial rehabilitation and clubhouse services

Combined countingUnits for both services are combined; psychosocial rehabilitation units count against clubhouse units and vice versa

Psychosocial Rehabilitation Group Size

Maximum group size12 recipients

ServicePsychosocial rehabilitation services

Delivery setting

Provider Requirements and Denial Risks

Denial Risk

Recipient Eligibility Required

Verify the recipient’s eligibility each time a service is rendered. Coverage requires Florida Medicaid enrollment on the date of service and satisfaction of the recipient criteria in this policy.

Confirm active Florida Medicaid enrollment on the date of service.
Confirm the recipient meets the policy’s eligibility requirements.

Denial Risk

Clinical Eligibility Required

Before billing, confirm that the recipient has a qualifying mental health diagnosis and requires medically necessary behavioral health community support services. The recipient must exhibit psychiatric, behavioral or cognitive, addictive-behavior, or other clinical conditions severe enough to significantly impair day-to-day functioning.

A qualifying mental health diagnosis is required.
Services must be medically necessary.
Document qualifying symptoms or clinical impairment.

Policy Background

Florida Medicaid behavioral health community support services promote recovery from behavioral health disorders or cognitive symptoms by helping recipients strengthen or regain the skills needed for successful functioning. Services are directed to recipients with a mental health diagnosis and psychiatric, behavioral, cognitive, addictive, or substantially impairing clinical conditions requiring medically necessary support, with objectives that include improving functional capabilities and supporting independent living.

Defined Terms

Claim Reimbursement Policy

Document typePolicy document found in Rule Division 59G, F.A.C.

PurposeProvides instructions on how to bill for services

Related activityClaim reimbursement

Coverage and Limitations Handbook or Coverage Policy

Document typePolicy document found in Rule Division 59G, F.A.C.

PurposeContains coverage information about a Florida Medicaid service

Policy subjectService coverage and limitations

Covered Treatment Modalities

Psychosocial rehabilitation services

Covered when all psychosocial rehabilitation criteria are met.

Psychosocial rehabilitation criteria: Restore or support skills and abilities necessary for independent living; address functional deficits and interpersonal or environmental barriers; restore social skills; ameliorate symptoms; and restore functional capabilities.Groups cannot exceed 12

May be delivered in a facility, home, or community setting.

Clubhouse services

Covered when all clubhouse service criteria are met.

Clubhouse service criteria: Provide structured, community-based, rehabilitative group services using behavioral, cognitive, or supportive interventions to improve social, occupational, educational, cognitive, and independent-living functioning.Recipient must be at least 16 years old; groups cannot exceed 12

Service Unit Limits

Behavioral Health Community Support Services Limit

Annual limit1,920 units per recipient per fiscal year

ServiceBehavioral health community support services

Combined servicesThe limit applies collectively to psychosocial rehabilitation and clubhouse services

Policy Summary

PayerAgency for Health Care Administration

PolicyBehavioral Health Community Support Services Coverage Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify each recipient's Florida Medicaid eligibility every time a service is rendered.

SourceLink

On This Page

May be provided in a facility, home, or community setting

Clubhouse Group Size

Maximum group size12 recipients

ServiceClubhouse services

Delivery requirementMust be delivered in a group setting

Clubhouse Minimum Age

Minimum ageAt least 16 years old

ServiceClubhouse services

Recipient requirementFlorida Medicaid recipients must meet the minimum age to receive clubhouse services

Denial Risk

General Non-Covered Conditions

Services are not covered when they fail medical-necessity criteria, the recipient fails eligibility requirements, or the service unnecessarily duplicates another provider’s service.

Does not meet the medical-necessity criteria in section 1.0.
Recipient does not meet the eligibility requirements in section 2.0.
Unnecessarily duplicates another provider’s service.

Denial Risk

Specific Non-Covered Services

Do not bill excluded services or circumstances under this benefit. Florida Medicaid specifically excludes the following services and settings.

Babysitting or child care services.
Case management.
Services provided on the day of admission into the Statewide Inpatient Psychiatric Program.
Services rendered to individuals residing in an institution for mental diseases.
Services rendered to institutionalized individuals as defined in 42 CFR 435.1009.
Transportation.
Travel time.

Documentation Required

Mental Health Diagnosis Documentation

Maintain documentation of a mental health diagnosis from a licensed practitioner in the recipient’s file. The diagnosis supports the clinical eligibility requirement for behavioral health community support services.

Keep the licensed-practitioner diagnosis in the recipient record.
Ensure the diagnosis is available to support the billed services.

Documentation Required

Daily Progress Notes Required

Maintain daily progress notes in the recipient’s file. Each note must list every service and activity provided that day.

Document services provided each day.
List each activity provided in the daily progress note.

Billing Rule

Annual Unit Limit

Florida Medicaid covers up to 1,920 units per recipient per fiscal year across behavioral health community support services. The combined total for psychosocial rehabilitation and clubhouse services cannot exceed this limit, and units from either service count against the other.

Annual limit: 1,920 combined units per recipient per fiscal year.
Units exceeding the combined limit are subject to denial or noncoverage.
Psychosocial rehabilitation units count against clubhouse units, and vice versa.

General Policies

TermA collective term for Florida Medicaid policy documents

SourceRule Chapter 59G-1, F.A.C.

ApplicabilityInformation applies to all providers, unless otherwise specified, rendering services to recipients

Medically Necessary/Medical Necessity

TermMedically Necessary/Medical Necessity

Definition sourceRule 59G-1.010, F.A.C.

Policy referenceDefined by the referenced Florida Administrative Code rule

Provider

Who it includesAny entity, facility, person, or group enrolled with AHCA

ProgramFlorida Medicaid

PurposeFurnishes services under the Florida Medicaid program in accordance with the provider agreement

Recipient

Who it isAn individual enrolled in Florida Medicaid

Managed careIncludes managed care plan enrollees

ProgramFlorida Medicaid

Treating Practitioner

DefinitionA licensed practitioner

RoleDirects the course of treatment for recipients

Treatment responsibilityProvides direction for the recipient’s course of treatment

Uses a wellness model and must be delivered in a group setting.