DraftOptumPolicy BH803 ID0102025

Assertive Community Treatment (ACT) — Idaho Medicaid Supplemental Clinical Criteria

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State-specific supplemental clinical criteria governing medical necessity, admission, continuation, discharge, provider qualifications, and exclusions for Assertive Community Treatment services for Idaho Medicaid members under Optum-managed behavioral health plans.

Policy Summary

PayerOptum

PolicyAssertive Community Treatment (ACT) — Idaho Supplemental Clinical Criteria

Policy CodePolicy BH803 ID0102025

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review Date

Key ActionVerify member eligibility and benefit plan coverage, and reference any state or federal regulatory requirements before applying these clinical criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24/7service availability

multidisciplinaryteam composition

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DraftOptumPolicy BH803 ID0102025

Assertive Community Treatment (ACT) — Idaho Medicaid Supplemental Clinical Criteria

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Policy Summary

PayerOptum

PolicyAssertive Community Treatment (ACT) — Idaho Supplemental Clinical Criteria

Policy CodePolicy BH803 ID0102025

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review Date

Key ActionVerify member eligibility and benefit plan coverage, and reference any state or federal regulatory requirements before applying these clinical criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24/7service availability

multidisciplinaryteam composition

6 momin unlicensed experience

18min unlicensed age

Idahoapplicable state

Coverage Criteria for Assertive Community Treatment (ACT)

inv-01: Initial Admission

Admission Criteria — Covered when ALL of the following are met:

Admission criteria for ACT: Member has a diagnosis of SPMI (Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, Severe Major Depressive Disorder, Delusional Disorder, Borderline Personality Disorder, or other Psychotic Disorder) AND is experiencing one or more specified functional/behavioral risk conditions (severity impacting independent community functioning; frequent emergency/inpatient use; homelessness/substandard housing; criminal justice involvement; struggles with substance use; requires ACT services to live safely and autonomously).1+ listed functional/behavioral condition

ACT services provided based on assessment of mental, physical, and behavioral condition and history to establish functional deficits and recovery goals.

inv-02: Continuation

Continuing Stay Criteria — Continued coverage requires ALL of the following:

Continuing medical necessity: Member continues to meet admission-level severity and functional impairment; is receiving individualized, person-centered, recovery-based treatment documented in a treatment plan; specific, measurable ACT recovery outcomes have been identified; member is making progress toward goals; transition and discharge plan is in place and updated as appropriate; interventions delivered by a high-fidelity ACT program per SAMHSA with multidisciplinary team, 24/7 availability, and frequent community contacts.progress toward goals plus documentation of high-fidelity ACT delivery

Outcomes may include reduced hospitalizations, reduced arrests/incarceration, increased housing stability, increased engagement with supports, and improved quality of life.

inv-03: Discharge

Discharge Criteria — Member no longer meets medical necessity when ANY of the following occur:

Discharge triggers: Treatment plan and discharge goals substantially met; consent for treatment withdrawn; individual no longer meets admission or continuing stay criteria; or member requires a different level of care (either more intensive or a lower/alternative level).

Services are not appropriate when the member’s primary diagnosis is one of the excluded conditions listed for ACT. Specifically, ACT is not appropriate for individuals with a primary diagnosis of dementia, intellectual disabilities, substance use disorders, personality disorders, organic disorders, or other non-intended recipients. Reviewers should deny coverage when the member’s presenting, primary diagnosis matches any of these exclusions and the service request is solely for ACT.

ACT Team Treatment Modalities

inv-15: ACT team-based community treatment

High-fidelity ACT program requirements: Delivered by a multidisciplinary team (psychiatrists, nurses, social workers, substance use specialists, vocational specialists, peer support specialists), 24/7 availability, frequent community contacts, evidence-based interventions per SAMHSA; services provided by licensed professional staff and unlicensed staff under supervision.

Team composition and licensed staff list specified by Idaho provider qualifications.

Provider Qualifications and Coding Requirements

Unlicensed staff experience requirement

Requirement>= 6 months documented direct care experience with individuals with Serious and Persistent Mental Illness (SPMI)

ContextExperience refers to documented direct care work supporting individuals with SPMI as part of ACT service delivery.

VerificationDocumentation must be available in personnel records or training/experience verification at time of hire or audit.

Unlicensed staff minimum age

Minimum age>= 18 years

Education prerequisiteMust have attained a high‑school diploma or equivalent (per staff requirements).

Required Provider Actions, Documentation, and Denial Risks

Prior Authorization

Verify eligibility and benefits

All reviewers must first verify the member's eligibility and specific benefits before applying these Clinical Criteria. Confirm the member is enrolled, the benefit plan covers the requested service, and whether any state or federal regulatory requirements or contract-specific provisions supersede the member's benefit plan. If the requested service is limited, excluded, defined differently, or conflicts with the member-specific benefit, the member's benefit language prevails.

Verify member eligibility and enrollment.
Confirm member-specific benefit coverage for the requested service.
Check for state or federal regulatory requirements or contractual provisions that supersede the benefit plan.
When benefit language conflicts with these Clinical Criteria, apply the member-specific benefit.

Documentation Required

PROVIDER ACTIONS

Key Definitions

ACT — Assertive Community Treatment

DefinitionAssertive Community Treatment (ACT) is an evidence‑based, client‑centered, recovery‑oriented community treatment and rehabilitation model delivered by a multidisciplinary mobile team to help members with severe, persistent mental illnesses live safely and autonomously in the community.

PurposeFacilitates community living, psychosocial rehabilitation, and reduced emergency/inpatient use for individuals who have not benefited from traditional outpatient programs.

SPMI — Serious and Persistent Mental Illness

DefinitionSerious and Persistent Mental Illness (SPMI): mental disorders associated with severe symptoms and functional impairment that significantly impact independent community functioning.

Included diagnosesSchizophrenia; Schizoaffective Disorder; Bipolar Disorder; Severe Major Depressive Disorder; Delusional Disorder; Borderline Personality Disorder; other Psychotic Disorders.

Background

Assertive Community Treatment (ACT) is an evidence-based, recovery-oriented, community treatment and rehabilitation model designed for individuals with Serious and Persistent Mental Illness (SPMI) who have severe symptoms and functional impairments and have not benefited from traditional outpatient programs. ACT uses a mobile, multidisciplinary team to deliver comprehensive, individualized services in the community with the goal of supporting independent community living, enhancing psychosocial rehabilitation, and reducing emergency and inpatient service use.

Policy Summary

PayerOptum

PolicyAssertive Community Treatment (ACT) — Idaho Supplemental Clinical Criteria

Policy CodePolicy BH803 ID0102025

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review Date

Key ActionVerify member eligibility and benefit plan coverage, and reference any state or federal regulatory requirements before applying these clinical criteria.

SourceLink

On This Page

Unlicensed staff provide services under professional staff supervision (formal and informal supervision required).

Providers must perform the general provider actions required to support authorization and ongoing coverage. This includes conducting a comprehensive clinical assessment, documenting diagnoses and relevant history, and ensuring services align with covered benefits. Obtain informed consent where applicable and maintain communication with the payer regarding changes in clinical status.

Complete a comprehensive clinical assessment and document diagnoses, functional impairments, and treatment history.
Document that the member meets admission criteria for ACT (SPMI diagnosis and functional impact) where applicable.
Ensure services requested are included in the member's benefit plan and submit any required prior authorization or supporting documentation.
Maintain timely updates to the treatment, transition, and discharge plans and notify the payer of significant changes in care or level of service.

Documentation Required

Treatment plan and outcomes documentation

Document an individualized, person-centered, recovery-based treatment plan that supports medical necessity for initiation and continuation of ACT services. The plan must specify measurable ACT recovery outcomes, interventions, responsible team members, frequency and location of services, and a transition/discharge plan.

Include individualized treatment goals and measurable outcomes (e.g., reduced hospitalizations, increased housing stability, reduced arrests).
Document that services are delivered by a high-fidelity ACT program per SAMHSA guidelines and by a multidisciplinary team.
Record frequency of contacts, community-based service locations, and 24/7 availability when applicable.
Maintain progress notes demonstrating movement toward goals and updates to the transition and discharge plan.

Denial Risk

Eligibility and exclusion-based denial risks

Services may be denied if the member does not meet admission criteria or has a primary exclusion. Reviewers should confirm the member meets SPMI admission criteria and that the primary diagnosis is not an exclusionary condition.

Denial risk if member does not meet SPMI admission criteria (e.g., diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, severe major depressive disorder, delusional disorder, borderline personality disorder, or other psychotic disorder with significant functional impairment).
Denial risk if the member's primary diagnosis is an exclusion (e.g., dementia, intellectual disability, primary substance use disorder, primary personality disorder, organic disorders).
Denial risk if services requested are not covered under the member's specific benefit plan or conflict with contractual/state requirements.

Use in criteriaA diagnosis of SPMI is required for ACT admission and must be accompanied by one or more specified functional/behavioral risk conditions (e.g., frequent emergency use, homelessness, criminal justice involvement, substance use struggles).