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DraftOptumPolicy BH803RI0102025

Rhode Island Medicaid Supplemental Clinical Criteria — Behavioral Health

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State-specific clinical criteria for behavioral health services under Rhode Island Medicaid managed by Optum, governing medical necessity determinations and program requirements for covered behavioral health services and specialized programs.

Policy Summary

PayerOptum

PolicyRhode Island Medicaid Supplemental Clinical Criteria — Behavioral Health

Policy CodePolicy BH803RI0102025

Change TypeNo material change

Effective DateOct 1, 2025

Next Review Date

Key ActionVerify member eligibility (Medicaid, age and program eligibility) and document required evaluations and treatment plans before initiating Home-Based Treatment Services (HBTS).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10+named programs

up to 20 hrs/wkHBTS max intensity

6 monthsformal plan review

90 daysnon-participation discharge

Coverage Criteria for Programs and Services

Clubhouse — Initial Participation

Clubhouse — Covered when ALL of the following are met

Clubhouse admission and plan: Member has a diagnosis from the listed set (schizophrenia; schizoaffective disorder; schizoid personality disorder; bipolar disorder; major depressive disorder, recurrent; obsessive-compulsive disorder; borderline personality disorder; delusional disorder; psychotic disorder) AND an activity plan is developed no later than 1 week after accessing Clubhouse with records signed by provider and member and at least a weekly progress note addressing each service provided.

Derived from admission and service delivery requirements.

EOS — Initial Therapy

Enhanced Outpatient Services (EOS) — Covered when ALL of the following are met

EOS admission: Member requires extended engagement and support through EOS to remain in the community (e.g., at risk of inpatient or residential treatment center admission, or requires a coordinated transition back into the community after inpatient/RTC) AND the member either meets adult Serious Mental Illness criteria or child/adolescent Serious Emotional Disturbance criteria.

Provider Requirements, Documentation, and Billing Alerts

Prior Authorization

HBTS eligibility verification (Medicaid, age, assistance program)

Verify member eligibility before initiating HBTS: member must be Medicaid eligible, age birth–21, and eligible for Medical Assistance through SSI, Katie Beckett (through age 18), Adoption Subsidy, Rite Care, or Rite Share; confirm the member has a potentially chronic (≥12 months) moderate to severe condition with significant functional compromise.

Member aged birth–21 and Medicaid eligible
Eligible via SSI, Katie Beckett, Adoption Subsidy, Rite Care, or Rite Share
Evidence of potentially chronic (≥12 months) moderate to severe cognitive, developmental, medical/neurologic and/or psychiatric condition

Prior Authorization

Confirm EOS admission criteria and need for extended engagement

For EOS admissions, confirm the member requires extended engagement/support to remain in the community (e.g., at risk of inpatient/RTC admission or needs coordinated transition) and that the member meets adult SMI criteria or child SED criteria before admission.

Program and Term Definitions

Clubhouse — key facts

DefinitionClubhouse is an outpatient program for adults recovering from severe and persistent mental illness that uses a therapeutic, work-ordered day and community supports to promote recovery, employment, education, housing, and improved quality of life.

Core componentsWork-ordered day with members and staff working side-by-side; transitional, supported, and independent employment at prevailing wages; access to housing, medical and educational supports; member participation in governance; outreach to maintain contact.

Availability & documentationTypically open at least 5 days per week; provider and member develop an activity plan no later than 1 week after access and maintain records signed by provider and member, including at least weekly progress notes addressing each service provided.

HBTS — Home-Based Treatment Services definition and scope

Definition & scopeHome-Based Treatment Services (HBTS) is an intensive home or community-based service for children and adolescents (birth–21) with chronic, moderate to severe cognitive, developmental, medical/neurologic and/or psychiatric conditions resulting in significant functional compromise.

Level of Care Criteria by Program

Home-Based Treatment Services (HBTS) — level-of-care criteria

Home-Based Treatment Services (HBTS) — level-of-care criteria (top-level nodes derived from source)

HBTS admission (level-of-care): Member is aged birth–21, Medicaid eligible, eligible via listed assistance programs, with a potentially chronic (>=12 months) moderate to severe condition and significant functional compromise; requires intensive therapeutic intervention; intensified outpatient services insufficient; safe home environment and willingness to participate.

Top-level admission criteria for HBTS.

HBTS continued stay (level-of-care): Severity and impairment continue to require HBTS; individualized, measurable treatment planning; active treatment with documented progress or justification for continued intervention.

Top-level continued stay criteria.

HBTS discharge (level-of-care): Documented treatment plan goals met; OR no longer meets initiation/continuing criteria or meets different level of care; OR consent withdrawn by youth 18+ or parent/guardian.

Allowed Treatment Modalities and Modal-Specific Criteria

HBTS (home/community-based intensive therapy)

HBTS (home/community-based intensive therapy) — modality-specific criteria and top-level node

HBTS modality criteria: HBTS is an intensive home/community-based modality for children/adolescents with chronic moderate to severe conditions whose functioning is significantly compromised; includes in-person, high-frequency specialized treatment (may include ABA discrete trial interventions); treatment intensity determined up to 20 hours/week based on clinical and family factors; provider ensures parental engagement and coordination with other services.up to 20 hours/week

Modality-specific treatment intensity and components.

Rehabilitative and therapeutic services

Rehabilitative and therapeutic services — modality definitions and criteria

Rehabilitation plan requirements: Rehabilitation and therapeutic service plans must include specific and measurable objectives, defined interventions to achieve skills/knowledge/resources, may include a personal safety plan when harm risk identified, and require review at least every 6 months.

Coding, Visit Limits, and Key Quantitative Rules

HBTS weekly hours

Maximum weekly HBTS hoursUp to 20 hours per week (providers assess intensity upon referral; ABA excluded from the 20‑hour calculation where noted).

Clubhouse planning timeline

Activity plan timelineThe provider and member must develop an activity plan as close to the date the member accessed Clubhouse, but no later than 1 week after accessing Clubhouse.

Daily Living Activities Functional Assessment (DLA) — threshold

DLA threshold for highest level of careIntegrated Health Home eligibility may be determined when the member meets the highest level of care on the Daily Living Activities Functional Assessment (DLA) with a score of >3.0-5.0.

Service Frequency and Review Intervals

EOS — recommended service frequency

Recommended frequencyEnhanced Outpatient Services (EOS) are recommended to be provided up to 5 days per week by the multidisciplinary team.

Clubhouse documentation requirement

Progress note requirementDocumentation must include at least a weekly progress note that addresses each service provided in Clubhouse; records are signed by provider and member.

HBTS treatment hours (excluding ABA)

HBTS treatment hours (excl. ABA)Upon referral, treatment intensity is assessed and may be up to 20 hours per week (excluding ABA programs).

Background and Scope

This document sets state-specific clinical criteria used to determine medical necessity for Rhode Island Medicaid behavioral health services managed by Optum. It defines covered programs (for example, Clubhouse, Enhanced Outpatient Services, Home‑Based Treatment Services), describes admission, continued stay and discharge criteria, and specifies service delivery and documentation expectations (including required evaluations, individualized treatment plans, and review intervals). Reviewers must verify member-specific eligibility and benefits before applying these criteria and follow the program-level exclusions and coordination requirements described herein.

Policy Revision History

2025-10annual_reviewLatest

Annual review and update (Version 10) published with effective date October 2025.

2024-09annual_review

Annual review and update (Version 9) completed in September 2024.

2023-06annual_review

Policy Summary

PayerOptum

PolicyRhode Island Medicaid Supplemental Clinical Criteria — Behavioral Health

Policy CodePolicy BH803RI0102025

Change TypeNo material change

Effective DateOct 1, 2025

Next Review Date

Key ActionVerify member eligibility (Medicaid, age and program eligibility) and document required evaluations and treatment plans before initiating Home-Based Treatment Services (HBTS).

SourceLink

On This Page

Services recommended up to 5 days per week and recommended ~4 hours/day by a multidisciplinary clinical team.

HBTS — Admission, Continued Stay, Discharge

Home-Based Treatment Services (HBTS) — Covered when ALL of the following are met

HBTS eligibility: Member is Medicaid eligible, aged birth–21, eligible via listed assistance programs (e.g., SSI, Katie Beckett, Adoption Subsidy, Rite Care/Rite Share), and has a potentially chronic (>=12 months) moderate to severe cognitive, developmental, medical/neurological and/or psychiatric condition with significant functional compromise; AND has impairments in one or more specified areas (cognitive functioning; problem solving; adaptive skills; regulation of mood; medical/neurological conditions) AND a formal diagnosis within the last 3 years by a qualified licensed professional consistent with DSM/ICD and expected to respond to HBTS.

Includes willingness of member and family to participate and safe home environment for staff.

HBTS preconditions and exclusions: Outpatient services at an intensified level have not been sufficient; there is evidence the member requires a comprehensive integrated program to support improved functioning at the least restrictive level of care; HBTS may not be provided when CAITS, CFIT, or EOS are being used.

Exclusion and precondition language.

HBTS continued stay: Severity of the member's condition and resulting impairment continue to require this level of treatment; individualized treatment planning with realistic and specific measurable goals and objectives is in place; active treatment is occurring with continued progress toward goals or documentation supports continued interventions.

Continued stay criteria require measurable progress or justification to continue.

HBTS discharge: The member's documented Treatment Plan goals and objectives have been successfully met; OR the member no longer meets service initiation or continuing care criteria or meets criteria for a less/more intensive level of care; OR consent for treatment has been withdrawn by a youth 18+ or parent/guardian.

Standard discharge conditions.

HBTS — Initial and ongoing treatment requirements

HBTS Service Delivery and Criteria

HBTS service requirements: Provider must document an evaluation by a licensed mental health professional within 2 years; utilize referral and collateral information (IEP, IFSP, provider/teacher contact, medical/behavioral records); identify and prioritize individualized, specific, measurable treatment goals and defined interventions; obtain parent/caregiver signature on treatment plans; assess and document treatment intensity up to 20 hours per week (excluding ABA) considering age, family ability to engage, severity, co-existing conditions, other services, functional capacities, and family factors; coordinate HBTS with referral sources and the member's medical home; and conduct a formal review of the treatment plan at least every 6 months.up to 20 hours/week

Operational requirements for initiation and ongoing delivery of HBTS.

IHH — Admission, Continued Stay, Discharge, and Service Delivery

Integrated Health Home (IHH) eligibility, continued stay, and service delivery

IHH admission: BHDDH must determine eligibility; member has a qualifying diagnosis (schizophrenia; schizoaffective disorder; schizoid personality disorder; bipolar disorder; major depressive disorder, recurrent; obsessive-compulsive disorder; borderline personality disorder; delusional disorder; psychotic disorder) OR significant functional impairment evidenced by Daily Living Activities (DLA) score >3.0-5.0.DLA >3.0-5.0

BHDDH determination and DLA threshold for functional impairment.

IHH continued stay: Services continue while medically necessary.

Standard continued stay requirement.

IHH discharge: Discharge when member reaches individually established goals and mutually agrees to termination; OR demonstrates ability to function in major role areas without program assistance and without significant relapse; OR has not participated in any service for 90 days despite documented engagement efforts.90 days non-participation

Discharge conditions including non-participation.

IHH service delivery requirements: On referral, complete a health assessment including suicide risk, depression, metabolic syndrome screen, alcohol/drug and tobacco use, chronic condition status, and perception of needs; confirm PCP and date of last visit; develop a person-centered plan addressing care coordination, chronic condition management, transitional care, and individual/family services; ensure collaboration with PCP/prescribers at least quarterly for members with significant medical morbidity; update assessment and plan at least every 6 months; and use health information technology to facilitate coordination and quality improvement.assessments and plan updated >= every 6 months

Operational and documentation requirements for IHH service delivery.

MHPRR — Admission, Continued Stay, Discharge, and Service Delivery

MHPRR admission, continued stay, and service delivery

MHPRR admission: BHDDH determines IHH eligibility; member is 18 or older and not under DCYF jurisdiction; has a qualifying diagnosis (schizophrenia; schizoaffective disorder; schizoid personality disorder; bipolar disorder; major depressive disorder, recurrent; obsessive-compulsive disorder; borderline personality disorder; delusional disorder; psychotic disorder); is receiving IHH services and active behavioral health treatment; referred by a physician; and meets one or more priority placement criteria (e.g., history of incarceration/institutionalization, dangerous behavior requiring structured supervision, requires assistance with ADLs, co-occurring conditions needing intensive monitoring, court-ordered outpatient treatment in compliance, or >1 psychiatric hospitalization in past year).age >=18 and IHH participation

Priority placement and referral requirements.

MHPRR continued stay: Services continue while medically necessary.

Standard continued stay requirement.

MHPRR service delivery: Initial evaluation assesses reasons for accessing services, readiness for rehabilitation, overall rehabilitation goal, functional skills/resources, and risk of harm; develop a multidisciplinary rehabilitation plan with specific measurable objectives and interventions; complete a personal safety plan when risk identified; provide outreach to members who are not attending; and review the rehabilitation plan at least every 6 months or more frequently with significant changes.review >= every 6 months

Operational service delivery and review timeline.

PASS — Admission, Continued Stay, and Discharge

PASS program eligibility and ongoing criteria

PASS admission: Enrollee aged birth–21 and Medicaid eligible; eligible for Medical Assistance via SSI, Katie Beckett (through age 18), Adoption Subsidy, Rite Care, or Rite Share; meets the federal definition of disability; lives at home with a consenting legal guardian; has impairments in activities of daily living, decision-making, or participation in social roles; has a formal diagnosis within the last 2 years by a qualified professional with standardized assessment evidence of functional impairment; symptoms consistent with DSM/ICD diagnosis requiring therapeutic intervention; family and enrollee willing to accept and cooperate; and home environment safe for PASS staff.diagnosis within 2 years; age birth-21

Admission, eligibility, and safety requirements.

PASS continued stay: Severity of condition(s) and resulting impairment continue to require a PASS service plan to maintain and/or improve adaptive and functional skills with standardized assessment evidence; progress toward goals is evident, measurable, and described in observable terms; and the family adheres to PASS treatment plan requirements.evidence of progress and ongoing impairment

Continued stay criteria.

PASS discharge: Discharge when the enrollee's documented Service Plan goals and objectives have been successfully met; OR the enrollee meets criteria for a less/more intensive level of care; OR the enrollee (age 18) or parent/guardian withdraws consent for treatment; OR loss of Medicaid eligibility.consent withdrawal or loss of eligibility

Discharge conditions.

Discharge Criteria

Discharge Criteria — Covered discharge when ANY of the following are met

Discharge criteria: The enrollee's documented Service Plan goals and objectives have been successfully met; OR the enrollee meets criteria for a less/more intensive level of care; OR the enrollee (age 18) or parent/guardian has withdrawn consent for treatment; OR loss of Medicaid eligibility.

Standard discharge conditions across programs.

Supported Employment Criteria

Supported Employment — Covered when ALL of the following are met

Admission and planning: Member has a qualifying diagnosis (schizophrenia; schizoaffective disorder; schizoid personality disorder; bipolar disorder; major depressive disorder, recurrent; obsessive-compulsive disorder; borderline personality disorder; delusional disorder; psychotic disorder) AND provider conducts an initial vocational evaluation addressing presenting issues, vocational needs, member goals, and develops a vocational/service plan.

Initial evaluation and plan development requirements.

Service elements: Supported Employment services include job seeking skills, job development and matching, job coaching, follow-along supports, benefits counseling, referrals to vocational/education services (e.g., Office of Rehabilitation Services), career counseling/training, transportation planning, and crisis access; plan coordinates with behavioral health providers.

Core service elements.

Service management: Ongoing work-based assessment; member-led individualized rapid job search prioritizing mainstream competitive jobs; plan review at least every 6 months (more often as needed); regular coordination with behavioral health team and employer involvement in reviews as appropriate.review >= every 6 months

Service management and review frequency.

Evidence-Based Practices Admission Criteria

Evidence-Based Practices (EBP) — Covered when ALL of the following are met

EBP eligibility: Member is aged birth–21 and Medicaid eligible (including SSI, Katie Beckett through age 18, Adoption Subsidy, Rite Care, or Rite Share).age birth-21

General eligibility across EBP models.

Clinical risk: Acute changes in signs/symptoms and/or psychosocial/environmental factors which suggest the member is at risk for out-of-home care or hospitalization, or requires ongoing multi-system involvement; condition can be safely and effectively treated in the EBP setting.

Risk/acuity requirement for EBP.

Target criteria by model: Multisystemic Therapy (MST): member aged 12-17, juvenile offender, externalizing behaviors consistent with disruptive/conduct disorders; Parenting with Love and Limits (PLL): member aged 10-18, juvenile offender, externalizing symptomatology or severe externalizing condition; Trauma Systems Therapy (TST): member aged 5-21 with ongoing emotion/behavior dysregulation due to trauma.

Model-specific target criteria.

PASS Service Delivery Criteria

PASS Service Delivery and Timing — Covered when ALL of the following operational steps are completed

Assessment and family readiness: Service plan begins with assessment of child and family daily routines; PASS Agency must assess family's readiness and ability to participate in consumer-directed approach and review family's ability to effectively participate.

Family readiness assessment and initial planning.

Timelines: PASS Agency offers first meeting within 14 calendar days of referral; completes assessment and service plan within 30 calendar days of the first meeting; and initiates services within 30 calendar days of signing the service plan.14/30/30 days

Explicit timing requirements for PASS delivery.

Service plan content and reassessment: Service plan must identify goals/objectives focused on PASS domains, include at least one home visit for health/safety assessment before plan submission, include reassessment of progress toward goals with revisions as needed agreed upon by all parties, and require reauthorization at least 15 calendar days prior to plan expiration.reauthorization >= 15 days prior

Operational content and reauthorization timing.

Home-Based Treatment Services (HBTS) are an intensive home- or community-based treatment for children and adolescents with chronic, moderate to severe cognitive, developmental, medical/neurologic and/or psychiatric conditions whose functioning is significantly compromised. HBTS provides in-person, high-frequency specialized treatment (including Applied Behavioral Analysis discrete trial interventions where appropriate) and is delivered with active engagement of the child/adolescent and parents/guardians. HBTS is not intended as respite or childcare and may not be provided when Child and Adolescent Intensive Treatment Services (CAITS), Child and Family Intensive Treatment (CFIT), or Enhanced Outpatient Services (EOS) are being used.

Member requires extended interaction with EOS to remain in community (examples: at risk of inpatient/RTC or needs transitional coordination)
Member is either an adult meeting Serious Mental Illness criteria or a child/adolescent meeting Serious Emotional Disturbance criteria
Services are recommended up to 5 days per week by a multidisciplinary team

Prior Authorization

Assess and document HBTS treatment intensity (up to 20 hrs/week)

Assess and document factors that determine HBTS treatment intensity upon referral; document rationale if approaching the maximum stated weekly limit.

Assess and record child’s age, ability to engage, diagnosis/course, severity of behaviors, other services received, family functioning, co‑existing/biologic conditions, current functional capacities, family factors, and interaction with other agencies
Determine intensity up to 20 hours per week (excluding ABA) based on these factors

Prior Authorization

PASS reauthorization completed ≥15 calendar days before plan expiration

PASS Agencies must complete reauthorization of the PASS service plan requiring renewal at least 15 calendar days before the existing approved plan expires; failure to reauthorize in time may risk service interruption.

Complete PASS reauthorization at least 15 calendar days prior to plan expiration
Delay or failure to reauthorize may interrupt services

Step Therapy

HBTS excluded if CAITS, CFIT, or EOS are in use

Do not provide HBTS concurrently with CAITS, CFIT, or EOS; HBTS is excluded when those intensive services are being used.

HBTS may not be provided when Child and Adolescent Intensive Treatment Services (CAITS), Child and Family Intensive Treatment (CFIT), or Enhanced Outpatient Services (EOS) are being used

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Documentation Required

Develop Clubhouse activity plan within 1 week and maintain weekly progress notes

For Clubhouse participation, develop an activity plan no later than 1 week after accessing Clubhouse; involve members in recordkeeping, obtain provider and member signatures on records, and document at least a weekly progress note addressing each service provided.

Activity plan developed by provider and member no later than 1 week after accessing Clubhouse
Members are involved in writing records and records are signed by provider and member
At least a weekly progress note that addresses each service provided

Documentation Required

HBTS documentation: evaluation, collateral, goals, caregiver signature, 6‑month reviews

For HBTS, ensure an evaluation by a licensed mental health professional within the prior 2 years is in the record; use referral and collateral information (IEP, IFSP, provider/teacher contact, medical/behavioral records); document individualized, specific, measurable treatment goals and obtain parent/caregiver signature on treatment plans; conduct formal plan review at least every 6 months.

Evaluation by a licensed mental health professional within 2 years
Use referral and collateral information (IEP, IFSP, contacts, records)
Individualized, specific, measurable goals with defined interventions
Parent/caregiver signs all proposed treatment plans
Formal review of the treatment plan at least every 6 months

Documentation Required

Document evaluations, collateral, treatment plans, parent involvement, and 6‑month reassessments

Document required evaluations and collateral, individualized measurable goals, expected parent/caregiver participation and signatures, and conduct formal reassessments at least every 6 months; for IHH include health assessment components (suicide risk, depression, metabolic screen) and PCP confirmation when applicable.

Licensed mental health professional evaluation within 2 years for HBTS
Use referral/collateral (IEP, IFSP, provider/teacher contact, medical records)
Individualized measurable treatment goals and clear expected parent/caregiver participation with signatures
Formal review/reassessment of treatment or service plans at least every 6 months
IHH health assessment must include suicide risk, depression, metabolic syndrome screen and confirm PCP and last visit

Documentation Required

Complete initial evaluation and develop documented service/rehabilitation plan; review ≥ every 6 months

Record the initial evaluation and assessment findings and use them to develop a service or rehabilitation plan that identifies goals, objectives, interventions, implementation details, and timelines; review the plan at least every 6 months or sooner if significant changes occur.

Initial evaluation gathers presenting issues, member goals, and vocational/nonwork needs as applicable
Service/rehabilitation plan includes specific measurable objectives and interventions and implementation details
Conduct formal review of the plan at least every 6 months and more frequently when there are significant changes

Denial Risk

Check member benefits first — benefit overrides clinical criteria

Before applying these Clinical Criteria, verify the member-specific benefit plan; if the requested service is limited or excluded by the member's benefit, the member-specific benefit supersedes these Clinical Criteria.

Identify member eligibility and benefit coverage prior to using Clinical Criteria
Member-specific benefit overrides these Clinical Criteria when conflicts exist

Denial Risk

90‑day non‑participation may trigger discharge/denial

If a member has not participated in any service for 90 days despite documented engagement efforts, providers may discharge the member and services may be denied for non‑participation.

Document outreach/engagement efforts
Discharge and potential denial may occur after 90 days of non‑participation despite outreach

Prior Authorization

Reauthorize PASS ≥15 calendar days before expiration to avoid service interruption

For PASS, complete reauthorization at least 15 calendar days prior to plan expiration; failure to do so risks interruption of services.

PASS Agency must renew reauthorization at least 15 calendar days before plan expiration
Failure to reauthorize timely may interrupt services

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Service componentsPhased, high-frequency in-person treatment (may include ABA discrete trial interventions), supervision of direct care staff, family/parent engagement, individualized measurable treatment goals and coordination with medical home and referral sources.

Intensity and assessmentProviders must evaluate treatment needs and determine intensity up to 20 hours per week (excluding ABA) based on age, severity, family ability to engage, co-occurring conditions, current functional capacities, and other listed factors.

EOS — Enhanced Outpatient Services definition

DefinitionEnhanced Outpatient Services (EOS) are home/community-based clinical services delivered by a multidisciplinary team to support transition from or prevent inpatient/residential admission and to help high‑risk members remain in the community.

Intensity & deliveryProviders offer varying intensity (multiple times per day tapering to multiple times per week); services are recommended up to 5 days per week and may include approximately 4 hours per day by a multidisciplinary clinical team.

PurposeUsed for prompt access, transition after inpatient stay, or to avoid admission for members at high risk, with team members having specialized clinical expertise as needed.

Integrated Health Home (IHH) — definition and services

DefinitionIntegrated Health Home (IHH) is a service delivered by behavioral health staff and peers that provides comprehensive care management, care coordination, transitional care, and linkages to community supports to ensure client stability and community tenure.

Service elementsIncludes comprehensive care management, care coordination and health promotion, transitional care from inpatient settings, individual and family support services, referrals to community supports, and use of health information technology to link services.

Eligibility assessment requirementBHDDH determines eligibility and IHH uses a health assessment (suicide risk, depression, metabolic screen, substance use, chronic conditions, PCP confirmation) to develop a person-centered plan updated at least every 6 months.

MHPRR — definition and services

DefinitionMental Health Psychiatric Rehabilitation Residence (MHPRR) is a licensed residential program that provides therapeutic, rehabilitative, and casework services to people who qualify for IHH, offered in various residential types (supportive apartments, basic, specialized residences).

Core servicesServices include counseling (individual, group, family), medication management and monitoring, social casework (advocacy, linkage, individualized treatment planning), limited physical assistance, and skill assessment and development.

Program requirementsInitial evaluation must assess reasons for services, readiness, rehabilitation goals, functional skills, and harm risk; multidisciplinary rehabilitation plan with measurable objectives and a personal safety plan when indicated; rehabilitation plan reviewed at least every 6 months.

PASS — definition, scope, and eligible age range

DefinitionPersonal Assistance Services & Supports (PASS) is a consumer-directed program providing intermittent to extensive one‑to‑one personal assistance to children (birth–21) with specified physical, developmental, behavioral, or emotional conditions living at home.

Goals & family roleSupports activities of daily living, decision-making, and social participation; maximizes family control and choice with families directing specific service delivery and leading supports for the child.

Timelines & initiationPASS Agency offers first meeting within 14 calendar days of referral, completes assessment and service plan within 30 calendar days of first meeting, and initiates services within 30 calendar days of signing the service plan.

Supported Employment — purpose and employment target

PurposeSupported Employment assists adults recovering from severe and persistent mental illness to find and keep meaningful jobs that pay at least minimum wage in integrated work settings (including people who are not disabled).

Program elementsIncludes job search, individualized rapid job development, job coaching, follow‑along supports, benefits counseling, referrals, transportation planning, crisis access, and coordination with behavioral health team.

Employment target & settingsPriority is mainstream competitive employment at or above prevailing minimum wage in integrated community work settings; plan reviewed at least every 6 months.

Evidence-Based Practices (EBP) — examples and scope

Definition & scopeEvidence-Based Practices (EBP) are home and community‑based treatment modalities for children with complex needs that provide an array of services across a continuum to improve care, reduce higher‑level care use, and improve quality.

Examples of EBP modelsExamples include Multisystemic Therapy (MST), Parenting with Love and Limits (PLL), and Trauma Systems Therapy (TST).

Target populationEBP are designed for Medicaid‑eligible children and adolescents (birth–21) with acute changes or complex psychosocial/environmental risk factors that place them at risk for out‑of‑home care or hospitalization.

Top-level discharge criteria.

Enhanced Outpatient Services (EOS) — level-of-care criteria

Enhanced Outpatient Services (EOS) — level-of-care criteria (top-level nodes)

EOS admission (level-of-care): Member requires extended engagement/support via EOS to remain in community (e.g., at risk of inpatient/RTC admission or requires transition support) AND meets adult SMI or child SED criteria.

Top-level EOS admission criteria; services recommended up to 5 days/week and approx. 4 hours/day by multidisciplinary team.

EOS service intensity: Services are provided at variable intensities (multiple times per day tapering to multiple times per week) to meet clinical needs; recommended up to 5 days/week and ~4 hours/day by a multidisciplinary team.up to 5 days/week; ~4 hours/day

Recommended service frequency and intensity.

Clubhouse (Outpatient Program) — level-of-care criteria

Clubhouse admission (level-of-care): Member diagnosed with one of the specified severe and persistent mental illnesses and seeks participation in a Clubhouse program focused on rehabilitation through a work-ordered day and community integration.

Admission aligns with Clubhouse program description and goals.

Clubhouse service delivery: Provider conducts initial evaluation assessing vocational/educational, social relationship and independent living goals; develops activity plan no later than 1 week after access; records signed by provider and member; at least weekly progress notes addressing services; Clubhouse typically open at least 5 days/week and offers additional social programs.activity plan <=1 week; weekly progress notes

Service delivery and documentation expectations.

Outpatient / Home-based (HBTS) — level-of-care criteria

Outpatient / Home-based (HBTS) — level-of-care criteria (alternate grouping)

HBTS admission elements (level-of-care): Member meets HBTS eligibility (age birth–21, Medicaid eligible, assistance program eligibility), has chronic moderate to severe condition with significant functional compromise, impairments in listed domains, formal diagnosis within last 3 years, requires intensive therapeutic intervention, and outpatient intensified services insufficient.

Admission elements consolidated.

HBTS service coordination and intensity: Provider assesses and documents treatment intensity up to 20 hours/week (excluding ABA), utilizes referral/collateral information, coordinates care with medical home and referral sources, and conducts formal plan review at least every 6 months.up to 20 hours/week; review >= every 6 months

Service delivery and coordination requirements.

HBTS discharge: Treatment plan goals met; OR no longer meets criteria or meets different level of care; OR consent withdrawn by youth 18+ or guardian.

Discharge conditions.

Integrated Health Home (IHH) — level-of-care criteria

Integrated Health Home (IHH) — level-of-care nodes and thresholds

IHH eligibility (level-of-care): BHDDH determines eligibility based on qualifying diagnoses OR DLA functional impairment (DLA score >3.0-5.0); BHDDH may qualify members without a diagnosis based on DLA findings.DLA >3.0-5.0

Eligibility includes diagnostic list and functional threshold.

IHH continued stay: Services continue while medically necessary.

Continued stay requirement.

IHH discharge: Member reaches goals and mutually agrees to termination; OR functions in major role areas without assistance and without significant relapse; OR has not participated in any service for 90 days despite engagement efforts.90 days non-participation

Discharge triggers including non-participation.

MHPRR — level-of-care criteria

MHPRR — level-of-care criteria for residential program admission and stay

MHPRR admission (level-of-care): Member is 18+ (not under DCYF), BHDDH determines IHH eligibility and member is receiving IHH services, is in active behavioral health treatment, referred by a physician, and meets one or more priority placement criteria (e.g., incarceration/institutionalization history, dangerous behavior requiring structured supervision, ADL assistance needs, co-occurring conditions requiring intensive monitoring, court-ordered outpatient compliance, or >1 psychiatric hospitalization in past year).age >=18 and IHH participation

Priority placement and referral requirements.

MHPRR continued stay: Services continue while medically necessary.

Continued stay requirement.

PASS — level-of-care criteria

PASS — level-of-care criteria for PASS program admission and continuation

PASS admission (level-of-care): Enrollee aged birth–21 and Medicaid eligible; eligible via listed assistance programs; meets federal definition of disability; lives at home with consenting guardian; has impairments in ADLs, decision-making, or social participation; formal diagnosis within last 2 years with standardized assessment evidence; symptoms require therapeutic intervention; family and enrollee willing to cooperate; safe home environment for staff.diagnosis within 2 years; age birth-21

Admission eligibility and safety.

PASS continued stay (level-of-care): Severity and impairment continue to require PASS service plan; measurable progress toward goals is evident; family adherence to plan requirements.evidence of progress and ongoing impairment

Continued stay criteria.

PASS discharge (level-of-care): Service Plan goals met; OR meets criteria for a less/more intensive level of care; OR enrollee (age 18) or guardian withdraws consent; OR loss of Medicaid eligibility.consent withdrawal or loss of eligibility

Discharge conditions.

Home and Community-Based/EBP, Supported Employment, PASS — cross-program level-of-care group

Cross-program eligibility: Programs for children (EBP, PASS) require member age within specified ranges (EBP/PASS: birth–21), Medicaid eligibility, and model-specific risk/target criteria; Supported Employment targets adults with qualifying diagnoses and vocational goals.age-specific per program

Top-level cross-program eligibility and distinctions.

Cross-program service planning: Initial evaluation and person-centered/service plans identify goals, measurable objectives, interventions, coordination with other providers, and require periodic review (at least every 6 months for many programs).review >= every 6 months

Common planning and review expectations.

review >= every 6 months

Documentation and plan content requirements.

EBP (MST, PLL, TST)

EBP (MST, PLL, TST) — Evidence-based practice nodes (three distinct EBP entries)

Multisystemic Therapy (MST): Member aged 12-17, juvenile offender, presents with externalizing behavior symptomatology consistent with disruptive/impulse-control and conduct disorders.age 12-17

Model-specific target criteria for MST.

Parenting with Love and Limits (PLL): Member aged 10-18, juvenile offender, presents with externalizing behavior symptomatology consistent with disruptive/impulse-control and conduct disorders or severe externalizing condition.age 10-18

Model-specific target criteria for PLL.

Trauma Systems Therapy (TST): Member aged 5-21 with ongoing trouble regulating emotions/behavior as a result of trauma.age 5-21

Model-specific target criteria for TST.

Supported Employment

Supported Employment — modality-specific criteria and service model

Supported Employment service model: Services must include initial vocational evaluation, individualized rapid job search and job matching, job coaching, follow-along supports, benefits counseling, referrals to vocational/education services, transportation planning, crisis access, and ongoing coordination with behavioral health team; plan review at least every 6 months.review >= every 6 months

Modality-specific service components and review schedule.

HBTS (eligibility and coding-relevant criteria)

HBTS — eligibility and coding-relevant criteria

HBTS coding-relevant eligibility: HBTS eligibility requires member be Medicaid eligible, age birth–21, eligible via listed assistance programs, with chronic moderate to severe condition and significant functional compromise; intensity may be up to 20 hours per week (excluding ABA) based on clinical and family factors.up to 20 hours/week

Eligibility elements tied to treatment intensity threshold.

Supported Employment — formal review interval

Plan review intervalSupported Employment vocational plan must be formally reviewed in collaboration with the member at least every 6 months (more often for significant change).

Annual review and update (Version 8) completed in June 2023.

2022-04annual_review

Annual review and update (Version 7) completed in April 2022.

2021-01annual_review

Annual review (Version 6) completed January 2021.

2020-01update

Version 5 published January 2020: Added Evidence‑Based Practice Criteria section and updated LOCUS/CASII/ECSII language.

2019-07update

Version 4 published July 2019.

2018-02update

Version 3 published February 2018.

2017-01update

Version 2 published January 2017.

2016-01publication

Version 1 published January 2016.