CurrentMontana Department of Public Health & Human ServicesPolicy N/A

Medicaid behavioral health state plan services — coverage criteria (behavioral health/SDMI, TMS, TCM, DBT, IMR, PACT/MCT, Day Treatment)

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Defines covered behavioral health services and program descriptions for Montana Medicaid members, including service types, purposes, and delivery settings; applies to providers furnishing these services under Montana DPHHS Medicaid.

Policy Summary

PayerMontana Department of Public Health & Human Services

PolicyMedicaid behavioral health state plan services — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument and maintain current biopsychosocial assessment and required treatment documentation, including reassessments at least every 90 days for Targeted Case Management.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18-27document chunks reviewed

90reassessment interval (days)

1:10Day Treatment ratio

24/7

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CurrentMontana Department of Public Health & Human ServicesPolicy N/A

Medicaid behavioral health state plan services — coverage criteria (behavioral health/SDMI, TMS, TCM, DBT, IMR, PACT/MCT, Day Treatment)

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Sign up for all Montana Department of Public Health & Human Services policy alerts

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Policy Summary

PayerMontana Department of Public Health & Human Services

PolicyMedicaid behavioral health state plan services — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument and maintain current biopsychosocial assessment and required treatment documentation, including reassessments at least every 90 days for Targeted Case Management.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18-27document chunks reviewed

90reassessment interval (days)

1:10Day Treatment ratio

24/7

PACT/MCT availability

>=18Min age for SDMI

12Biopsych assessment recency (mo)

Coverage Criteria

COVERAGE CRITERIA

Covered when ALL of the following are met

TMS coverage prerequisites

SDMI diagnostic pathways: Either involuntary hospitalization for at least 30 consecutive days at Montana State Hospital or the Montana Mental Health Nursing Care Center within the past 12 months OR diagnosis in an enumerated category (Schizophrenia spectrum, Schizoaffective, Delusional disorder, Bipolar, Depressive disorders, PTSD, Personality disorders, Neurodevelopmental disorders, and other listed diagnoses). If criteria (a) or (b) are not met, the provider must complete the SDMI Eligibility and LOI Worksheet to determine eligibility.>= 30 consecutive days for involuntary hospitalization pathway
Providers must maintain supporting documentation (biopsychosocial assessment within 12 months and SDMI certification) and related clinical records for utilization review.

Covered when ALL of the following are met: the member meets the program-level prerequisites for the specified service, including a designation of Severe Disabling Mental Illness (SDMI) certified by a licensed clinical mental health professional with a current biopsychosocial assessment within the last 12 months; the member is ≥ 18 years of age and has a diagnosable mental illness within the past 12 months that interfered with functioning and causes significant difficulty in community living without long‑term/supportive treatment or services; and the member meets one of the SDMI diagnostic pathways — either an enumerated qualifying diagnosis from the covered ICD‑10 group or a history of involuntary hospitalization of ≥ 30 consecutive days at specified Montana state facilities within the prior 12 months.

The extract does not include any explicit statements labeling services as not medically necessary. The source material notes that Transcranial Magnetic Stimulation (TMS) is a noninvasive alternative for treatment‑resistant depression when medication trials have failed or are not tolerated, but no explicit not‑medically‑necessary language or blanket exclusions are present in this excerpt.

Coding and Diagnostic Criteria

SDMI covered diagnosesICD-10Covered

F20.0	Schizophrenia, paranoid type
F20.1	Schizophrenia, disorganized type
F20.2	Schizophrenia, catatonic type
F20.3	Schizophrenia, undifferentiated
F20.5	Schizophrenia, residual type
F22	Delusional disorder
F25.0	Schizoaffective disorder, bipolar type
F25.1	Schizoaffective disorder, depressive type
F31.12	Bipolar I disorder, manic without psychotic features, moderate
F31.13	Bipolar I disorder, manic without psychotic features, severe

1–10 of 41

1/5

Involuntary hospitalization duration — SDMI qualifying criterion

Minimum involuntary hospitalization duration>= 30 consecutive days (at MSH or MMHNCC within past 12 months)

Relevant facility locationsMontana State Hospital (MSH) or Montana Mental Health Nursing Care Center (MMHNCC)

Lookback periodWithin the past 12 months

Biopsychosocial assessment recency

Required assessment recencyBiopsychosocial assessment completed within the last 12 months

Certifying professionalMust be established/certified by a licensed clinical mental health professional

Provider Actions, Documentation & Authorization

Note

TMS usage note

Transcranial Magnetic Stimulation (TMS) is a noninvasive procedure indicated for treatment‑resistant depression and is presented in the policy as an alternative when medication trials are not effective or medication side effects are intolerable.

Prior Authorization

Pre-Authorization and Continued Stay Reviews required via MPQH portal

Some behavioral health services require pre‑authorization (PA) and/or continued stay review (CSR); when required these reviews are completed through Mountain Pacific Quality Health's authorization portal and follow the BHDD policy manual.

Not all services require PA or CSR; check the service’s utilization management section for specific requirements.
If a PA or CSR is required it must be submitted via Mountain Pacific Quality Health's authorization portal.

Background and Scope

The document defines and lists behavioral health services intended to help members with treatment-resistant conditions and significant functional impairment. One specific modality described is Transcranial Magnetic Stimulation (TMS), defined as a noninvasive procedure for treatment-resistant depression that uses magnetic fields to stimulate brain nerve cells to improve depressive symptoms. TMS is presented as an alternative when medication trials fail or medication side effects are intolerable, and is targeted to adults meeting clinical criteria for treatment-resistant depression.

Service Definitions

Targeted Case Management (TCM)

DefinitionTargeted Case Management (TCM): services to assist members in gaining access to needed medical, social, educational, and other services

Core activitiesComprehensive assessment; care plan development and periodic revision; referrals and scheduling; monitoring and follow-up

Assessment frequency requirementPeriodic reassessment at least once every 90 days

Annual monitoringAt least one annual monitoring contact is required as part of follow-up activities

Illness Management and Recovery (IMR)

DefinitionIllness Management and Recovery (IMR): an evidence-based program that teaches individualized strategies for managing mental illness

Level-of-Care Criteria

Treatment Modalities

Dialectical Behavior Therapy (DBT)

DBT provider requirement: DBT can be provided by any licensed clinical mental health professional who is trained to provide it.

Evidence-based cognitive-behavioral treatment.

Transcranial Magnetic Stimulation (TMS)

TMS indication: TMS is indicated for treatment-resistant depression when medication trials have failed or medication side effects are intolerable.treatment-resistant depression

TMS is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression.

Illness Management and Recovery (IMR)

Visit Limits and Ratios

Day Treatment staff-to-member ratio

Maximum staff-to-member ratioNo more than 1 staff to 10 members (<= 1:10)

Service settingDay Treatment (Day TX) — community-based alternative to more restrictive care

Program directionServices directed by program supervisor and/or licensed clinical mental health professional

Policy Summary

PayerMontana Department of Public Health & Human Services

PolicyMedicaid behavioral health state plan services — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument and maintain current biopsychosocial assessment and required treatment documentation, including reassessments at least every 90 days for Targeted Case Management.

SourceLink

On This Page

Documentation maintenanceAssessment supports SDMI designation and must be current for eligibility

Age requirement for SDMI

Minimum age for SDMI designation>= 18 years

Age requirement contextMember must be 18 years or older at time of SDMI certification

Associated criteriaAge is one of multiple SDMI eligibility elements (diagnosis, functioning, need for long-term services)

Step Therapy

TMS implies prior medication trials (stepped care)

The policy positions TMS as an alternative after trials of medication have failed or when medications are not tolerated, implying that medication trials (stepped care) are expected before TMS is used.

Note

TMS as alternative after medication trials fail or are intolerable

TMS is considered an alternative treatment option when medication trials are not working and/or medication side effects are intolerable for the member; document prior medication trials and intolerance when applicable.

Documentation Required

TCM documentation and reassessment requirements

For Targeted Case Management (TCM), providers must document a comprehensive assessment, periodic reassessments at least once every 90 days, development and periodic revision of a specific care plan, referral and scheduling activities, and monitoring/follow‑up including at least one annual monitoring.

Comprehensive assessment and periodic reassessment at least once every 90 days.
Development and periodic revision of a specific care plan based on the assessment.
Referral and related activities (e.g., scheduling appointments).
Monitoring and follow‑up activities, including at least one annual monitoring.

Documentation Required

Required clinical documentation

Providers must maintain the following clinical records to support behavioral health services: Biopsychosocial Assessment, Individualized Treatment Plans, Progress Notes, Continuing Care Plan, and Discharge Plan and Summary.

Biopsychosocial Assessment
Individualized Treatment Plans
Progress Notes
Continuing Care Plan
Discharge Plan and Summary

Documentation Required

SDMI certification and assessment recency

SDMI designation must be certified by a licensed clinical mental health professional and supported by a current biopsychosocial assessment completed within the last 12 months.

Certification by a licensed clinical mental health professional.
Biopsychosocial assessment completed within the last 12 months.

Documentation Required

TCM periodic reassessment interval (every 90 days)

Targeted Case Management requires periodic reassessment at least once every 90 days; failure to perform these reassessments risks noncompliance with TCM service definitions.

Comprehensive assessment and periodic reassessment at least once every 90 days are required.

Denial Risk

Denial risk for services requiring PA/CSR

Services that require pre‑authorization or continued stay review but are not approved may be denied; members and providers may pursue appeals through the Department’s fair hearing process as outlined in the BHDD policy manual.

PA and CSR that are required must be submitted and approved; lack of approval can result in denial.
There is a fair hearing process within the Department for denials.

GoalsReduce disability, restore functioning, provide illness information and coping skills, support goal setting and action in daily life

Ongoing reviewGoals are reviewed on an ongoing basis by the provider, behavioral aide, and member

Transcranial Magnetic Stimulation (TMS)

DefinitionTranscranial Magnetic Stimulation (TMS): a noninvasive procedure using magnetic fields to stimulate nerve cells in the brain

IndicationUsed for treatment-resistant depression when medication trials are not working or side effects are intolerable

PurposeTo improve symptoms of depression by stimulating brain nerve cells

Transcranial Magnetic Stimulation (TMS) — alternate phrasing

Alternate wordingTMS is a noninvasive procedure for treatment-resistant depression that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression

Usage implicationPositioned as an alternative when medication trials fail or medications are not tolerated

Clinical placementConsidered when medication side effects are intolerable or ineffective

Severe Disabling Mental Illness (SDMI) — designation & certification

DefinitionSevere Disabling Mental Illness (SDMI): designation certified by a licensed clinical mental health professional supported by a current biopsychosocial assessment

Core eligibility elementsAge >=18; diagnosable mental illness in past 12 months interfering with functioning; significant difficulty in community living without long-term/supportive services

Certification requirementSDMI must be certified by a licensed clinical mental health professional

IMR goals: IMR teaches individualized strategies to manage mental illness, reduce disability, restore functioning, and set and pursue personal goals with ongoing review by provider, behavioral aide, and member.

Evidence-based program emphasizing skill-building and goal-directed action.

Transcranial Magnetic Stimulation (TMS)

TMS treatment modality criteria: TMS is a noninvasive procedure for treatment-resistant depression and is an alternative when medication trials fail or medication side effects are intolerable.

Used as alternative to pharmacotherapy when trials are ineffective or not tolerated.