DraftOptumPolicy BH803!D0102025

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

State-specific clinical criteria for Assertive Community Treatment services used to determine medical necessity for Idaho Medicaid Plus members managed by Optum Behavioral Health Solutions.

Policy Summary

PayerOptum

PolicyAssertive Community Treatment (ACT) Supplemental Clinical Criteria — Idaho Medicaid Plus

Policy CodePolicy BH803!D0102025

Change TypeNo material change

Effective DateOctober, 2025

Next Review DateN/A

Key ActionDocument member-specific benefits, eligibility, and state or contractual requirements when making medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24/724/7 availability

6 monthsUnlicensed staff experience

18Unlicensed staff minimum age

High-fidelityProgram fidelity

Coverage Criteria for ACT Services

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Admission Criteria: Member has 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 of the following: severity of symptoms significantly impacting independent community functioning; frequent emergency/inpatient psychiatric or medical service use; homelessness or substandard housing; involvement in the criminal justice system; struggles with substance use; or requires ACT services to live safely and autonomously in the community. ACT services based on assessment of mental, physical, and behavioral condition and history to establish functional deficits and recovery goals.

Based on chunk 5

Continuing Stay Criteria

Continued coverage when ALL of the following are met

Continuing Stay Criteria: Member's severity of symptoms and functional impairments continue to meet admission criteria AND member is receiving individualized, person-centered, recovery-based treatment and supports documented in a treatment plan AND specific, measurable ACT recovery outcomes have been identified (examples: reduced hospitalizations/ER use, reduced arrests/incarceration, increased housing stability, engagement with employment/education, improved quality of life) AND member is making progress toward individualized goals AND a transition/discharge plan is in place and updated as appropriate AND interventions are evidence-based and delivered by a high-fidelity ACT program (multidisciplinary team, 24/7 availability, frequent community contacts).

Based on chunk 6

Discharge Criteria

Discharge when ANY of the following are met

Discharge Criteria: The individual's treatment plan and discharge goals have been substantially met OR consent for treatment has been withdrawn OR the individual no longer meets the admission or continued stay criteria OR the member requires a more intensive or a more appropriate lower level of care.

Based on chunk 7

ACT is not appropriate for individuals whose primary diagnosis is one of the conditions listed under exclusions. Specifically, do not use ACT as the primary service for members with a primary diagnosis of dementia, intellectual disabilities, primary substance use disorders, personality disorders, or organic disorders. The policy also notes that ACT should not be used for non-intended recipients (individuals for whom the model is not clinically appropriate).

Assertive Community Treatment Modalities

ACT (Assertive Community Treatment)

ACT Service Delivery: Services delivered by a multidisciplinary team including psychiatrists, nurses, social workers, substance use specialists, vocational specialists, and peer support specialists; interventions are evidence-based; frequent community contacts (often multiple times per week) with services delivered in community settings; and 24/7 service availability as part of a high-fidelity ACT program per SAMHSA.

Based on chunks 6 and 9

Provider Qualifications & Coding-related Notes

Unlicensed staff experience and minimums

Minimum documented direct care experience>= 6 months documented direct care experience with individuals with SPMI

Minimum ageAt least eighteen (18) years old

Education requirementHigh-school diploma or equivalent

Required trainingCompleted State Medicaid Agency designated training

SupervisionUnlicensed staff must receive formal and informal professional staff supervision and clinical consultation

Provider Actions, Documentation, and Denial Triggers

Prior Authorization

Medical necessity determination — reference member-specific benefits, eligibility, and state/contractual requirements

Medical necessity determination: Reviewers must verify member-specific benefits, eligibility, and any applicable state or contractual requirements before applying these clinical criteria. The member's benefit plan and regulatory requirements supersede these Clinical Criteria if there is a conflict.

Confirm member eligibility and enrollment for the requested service.
Verify the member-specific benefit language for coverage, limitations, or exclusions; if benefits limit or exclude the service, the benefit controls.
Identify any state or contractual regulatory requirements that supersede member benefits or these Clinical Criteria.
Document how the member meets admission or continuing stay criteria (SPMI diagnosis, functional impairment, utilization history, homelessness/criminal justice involvement, substance use, need for ACT services).
Ensure the requested service aligns with program requirements (e.g., ACT high-fidelity elements, multidisciplinary team, 24/7 availability) when applicable.

Step Therapy

Step therapy — provider guidance

Step therapy / utilization management: No specific step therapy sequence is defined here. Providers should consult the member's benefit plan and any plan-specific utilization management rules for required prior authorization or sequencing prior to delivering services.

If the member's plan includes step therapy, follow the plan's defined sequence and document trials of required prior interventions.
Check for plan-level prior authorization requirements and submit required clinical documentation supporting medical necessity.

Documentation Required

Required clinical documentation

Required clinical documentation: Requests must include documentation supporting an SPMI diagnosis, functional impairment, and the presence of listed risk factors or needs that justify the level of service.

Clinical assessment documenting SPMI diagnosis (e.g., Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, Severe Major Depressive Disorder, Delusional Disorder, Borderline Personality Disorder, or other Psychotic Disorder).
Description of functional impairment and how symptoms limit independent community functioning.
Evidence of frequent utilization of emergency, inpatient medical, or psychiatric services if applicable.
Documentation of homelessness or substandard housing, criminal justice involvement, substance use concerns, or other risk factors cited in admission criteria.
Individualized, person-centered treatment plan with specific, measurable ACT recovery outcomes and progress notes showing interventions and member response.
For continuing services, documentation of high-fidelity ACT program elements (multidisciplinary team composition, contact frequency, community-based services, 24/7 availability) and a transition/discharge plan when appropriate.

Denial Risk

Triggers for denial — unmet admission/continuing criteria or documentation requirements

Triggers for denial: Requests may be denied when admission criteria or required documentation are not met, or when the member's benefit excludes or limits the requested service.

Denial if the member does not have a qualifying SPMI diagnosis or documentation of functional impairment as specified in admission criteria.
Denial if required clinical documentation (assessment, treatment plan, evidence of risk factors, progress toward goals, or ACT program fidelity) is missing or insufficient.
Denial if the member's benefit plan excludes the service or defines the service differently than these Clinical Criteria.
Denial if the member's primary diagnosis is listed in exclusions (e.g., Dementia, Intellectual Disabilities, primary Substance Use Disorder, certain Personality Disorders, Organic Disorders) making ACT inappropriate.

Definitions

Assertive Community Treatment (ACT) — definition and model

DefinitionClient-centered, recovery-oriented, evidence-based service delivery model delivered by a multidisciplinary team to facilitate community living, psychosocial rehabilitation, and recovery for persons with the most severe and persistent mental illnesses.

Primary goalRecovery through community treatment and rehabilitation to enable safe, autonomous community living

Key featuresMultidisciplinary team delivery, frequent community contacts, individualized treatment plans with measurable outcomes, and high-fidelity ACT program standards

Intended populationRelatively small group diagnosed with SPMI who have intractable symptoms and serious problems living independently

Examples of Serious and Persistent Mental Illness (SPMI)

SchizophreniaListed example of SPMI

Schizoaffective DisorderListed example of SPMI

Bipolar DisorderListed example of SPMI

Severe Major Depressive DisorderListed example of SPMI

Delusional DisorderListed example of SPMI

Borderline Personality DisorderListed example of SPMI

Other Psychotic DisorderListed example of SPMI

Background

Assertive Community Treatment (ACT) is an evidence-based, community-based, multidisciplinary service 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 is delivered by a multidisciplinary team to support community living, psychosocial rehabilitation, and recovery through intensive, person-centered services.

Key features of ACT described in this policy include delivery by a high-fidelity multidisciplinary team (psychiatrists, nurses, social workers, substance use specialists, vocational specialists, and peer support specialists), provision of evidence-based interventions, frequent community contacts, and 24/7 availability to meet member needs. ACT emphasizes individualized treatment plans with measurable recovery outcomes, outreach in community settings, and supports aimed at helping members live safely and autonomously in the community.