Medicaid Waiver Home-Based Family Treatment Services Playbook
- What is Alaska’s Medicaid 1115 Behavioral Health Waiver and what does it do?
- How does the waiver pay for Home-Based Family Treatment Services?
- How can my organization bill Medicaid for Home-Based Family Treatment Services?
- Understanding Level 1 Home-Based Family Therapy
- What screening tools can be used to qualify for HBFT L1 services?
- Practical Guide for HBFT L1 Service Delivery
Testimonials
*This Home-Based Family Treatment Services Medicaid Waiver Playbook was written by Pam Miller, LCSW of Behavioral Health Compliance Solutions, LLC, in collaboration with Randy Bendle, Operations Director at Alaska Family Services.
What is Alaska’s Medicaid 1115 Behavioral Health Waiver and what does it do?
The State of Alaska, Department of Health and Social Services (DHSS) implemented a demonstration waiver January 1, 2019. Demonstration waivers allow states to test new or existing ways to deliver and pay for health care services in Medicaid and the Children’s Health Insurance Program (CHIP). Although this demonstration period ends December 31, 2023, DHSS is submitting a renewal application to continue this demonstration for another five-year period from January 1, 2024, to December 31, 2028. A general overview of the behavioral health waiver can be found here.
The goal of the waiver is to “create a data-driven, integrated behavioral health system of care for Alaskans with serious mental illness, severe emotional disturbance, and/or substance use disorders”.
How does the waiver pay for Home-Based Family Treatment Services?
This waiver provides flexibility to offer a broad range of substance use and behavioral health services. One of the behavioral health services, Home-Based Family Treatment Services Level 1 (HBFT L1), is delivered to children/youth under the age of 21 and is designed to be a community-based early intervention service. Services include treatment and wrap-around services provided to reduce the need for inpatient hospitalization and residential services for children/adolescents.
There are 3 levels of HBFT available to children in the state:
- Level 1 services are provided to a child/youth at risk of out-of-home placement or diagnosed with or at risk of developing a mental, emotional, or behavioral disorder or substance use disorder as determined by a screening tool.
- Level 2 services are provided to a child/youth at high risk of out-of-home placement.
- Level 3 services are provided to a child/youth who is at imminent risk of out-of-home placement or who has been discharged from a residential treatment program, psychiatric hospital, or juvenile detention facility.
How can my organization bill Medicaid for Home-Based Family Treatment Services?
Understanding Level 1 Home-Based Family Therapy
The focus of this playbook is to provide a guide to implement HBFT Level 1 (HBFT L1) services. To provide these services, there are several criteria that must be met.
Criteria for Organizations
- Must meet the regulatory requirements for Community Behavioral Health Service Provider (CBHS). To enroll as a CBHS, behavioral health service providers must meet the requirements in the Integrated Behavioral Health Regulations, 7 AAC 70 and 7 AAC 135, and Behavioral Health 1115 Waiver Demonstration Regulations, 7 AAC 136 and 139. These regulations can be found at Infobases. In addition, the Alaska Behavioral Health Providers Services Standards & Administrative Procedures for Behavioral Health Provider Services has been adopted by regulation, which means this manual also needs to be adhered to. It and other applicable documents can be found at 1115 Behavioral Health Medicaid Waiver. Please note that this manual, as well as waiver regulations, are pending revisions at the time of the writing of this playbook.
- After meeting these requirements, the service provider organization must be enrolled in the Medicaid program as a CBHS. Providers can enroll at Alaska Medicaid Health Enterprise. The CBHS must submit a signed Provider Agreement, certifying the provider agrees to comply with applicable laws and regulations. If enrollment information changes, providers must report the changes within 30 days of the change in writing with an original signature.
- The CBHS must be approved by the Alaska Division of Behavioral Health to provide waiver services. To receive approval, the organization should submit the application.
Organization Training
Online training is also available to guide providers through the enrollment process. To view this training, visit the Alaska Medicaid Learning Portal. If extenuating circumstances prevent a provider from enrolling online, please contact the Provider Enrollment Department. Once enrollment is approved, the provider should receive a Medicaid Provider identification number (ID) and a welcome packet.
Criteria for Direct Service Providers (staff members)
- Providers must complete a background check.
- Providers must have a National Provider Identification Number (NPI). To obtain an NPI, go to NPPES.
- Providers must be enrolled as an Alaska Medicaid program provider as a Qualified Behavioral Health Professional (QBHP) affiliated with the CBHS found here: Alaska Medicaid Health Enterprise.
- All waiver services must be provided by qualified staff. To become qualified, please refer to the Alaska Behavioral Health Providers Services Standards & Administrative Procedures for Behavioral Health Provider Services.
- Staff can apply for qualification here.
- Once approved, qualified staff may start providing HBFT L1 services.
Criteria for child/youth receiving Home-Based Family Treatment Levels 1-3
- Individuals must be eligible for Medicaid. Individuals ages 0-18 can apply for Denali KidCare. Those older than 18 years old can apply for Medicaid here.
- Individuals must be under the age of 21.
- The individual must have or be at risk of being diagnosed with a mental health or substance use disorder. “At risk” is based on the results of a screening tool (see the Screening Tools section of this playbook). This is a requirement for HBFT L1.
- The individual may be at risk of out-of-home placement.
- The individual may be in the custody of the State or be detained in a juvenile justice facility or treated in a residential treatment program or psychiatric hospital within the past year.
- Youth between the ages of 18 and 21 may be eligible as adults for certain wavier services. This eligibility depends on their eligibility under Early Periodic Screening, Diagnosis, and Treatment (EPSDT) provision in Medicaid. For more information on EPSDT, visit Health Care Services.
Who qualifies for HBFT L1 Services?
HBFT L1 can be delivered to children and youth that either:
- have a behavioral health diagnosis or
- are identified as being at risk of developing a diagnosable behavioral health disorder
What services are covered under HBFT L1?
HBFT L1 can encompass a variety of services designed to assist the youth and family to develop skills and obtain necessary resources.
The specific service components are:
- Crisis diversion & intervention planning
- Case coordination & referral
- Ongoing monitoring for safety and stability in the home
- Skill development including:
- Assisting parents to utilize developmentally appropriate strategies to restore functioning and provide structure/support for children with emotional/behavioral problems.
- Communication, problem-solving and conflict-resolution skill building
- Life/social skills required to restore functioning and provide structure and support for children with emotional and behavioral problems.
- Self-regulation, anger management, and other mood management skills for children, adolescents, and parents
- Peer supports & navigation
- Clinical services (with clinical assessment and treatment plan)
- Comprehensive family assessment
- Family, group, and individual therapy (delivered and billed as waiver service UNLESS the youth has been diagnosed with a behavioral health disorder as identified through a Behavioral Health Assessment and recommended and prescribed on Treatment Plan. In this case, therapy can be delivered and billed for separately).
- Linkage to medication services—including medication administration
Where can HBFT L1 Services be delivered?
HBFT L1 can be delivered:
- in the home, or
- in an appropriate community-based setting (such as schools, shelters, visitation offices, etc.).
HBFT L1 cannot be delivered:
- in an inpatient or residential institutional setting, however
- there is an exception that allows for HBFT L1 to be delivered to youth in residential treatment or Psychiatric Residential Treatment Facilities (PRTF) for up to 12 calendar days per year as part of a discharge plan from a residential treatment facility for an adult or child in the home.
Who can deliver HBFT L1 services?
- a variety of staff if they are qualified, as previously described and outlined in the Alaska Behavioral Health Providers Services Standards & Administrative Procedures for Behavioral Health Provider Services
- a multi-disciplinary team
What screening tools can be used to qualify for HBFT L1 services? `
HBFT L1 providers must use a screening tool to identify recipient problems with one or more social determinants of health as listed in the ICD-10 (Z codes).
What Is a Screening Tool? A screening tool is a brief list of questions relating to a child’s behavior, thoughts, and feelings. It usually takes only 5–15 minutes to answer. A specific method is used to score the answers to the questions, and the score suggests the degree to which the child may have a problem. When a score indicates a likely problem, it is called a positive finding; when the score indicates that a problem is not likely, it is called a negative finding (Substance Abuse and Mental Health Services Administration- SAMHSA).
Youth Screening Tools
The Division of Behavioral Health (DBH) recommends that screening tools used under the waiver for screening cover both mental health, substance use disorder and trauma. The Division has not mandated the use of a particular tool exclusively and encourages providers to select an evidenced based screening tool that best meets the needs of the population served. Here are some ideas for a cost-free screening tool:
- The Alaska Screening Tool (AST)
- The Pediatric Symptom Checklist (PSC)
- Adverse Childhood Experiences (ACES)
- The Brief Impairment Scale (BIS)
- Center for Epidemiological Studies Depression Scale for Children (CES-DC)
- Child/Adolescent Psychiatry Screen (CAPS)
- Childhood Severity of Psychiatric Illness (CSPI)
- Childhood Trust Events Survey (CTES)
- Children’s Impact of Event Scale (CRIES-8)
- Columbia Impairment Scale (CIS)
- COPE Inventory (COPE)
- Depression, Anxiety and Stress Scales (DASS)
This guide may assist you in finding an appropriate screening tool.
The National Institute for Mental Health (NIMH) recommends the Revised Children’s Anxiety and Depression Scale. There are limitations on the copywrite, so please read for your information. In addition, this page identifies other tools that may be useful.
According to SAMHSA:
- All screening instruments should be shown to be valid and reliable in identifying youth in need of further assessment.
- Screening must be developmentally, age, gender, and racially/ethnically/culturally appropriate for the recipient to the greatest degree possible and use of results should be informed by potential limits to validity as indicated.
- Early identification procedures and approaches should respect and take into consideration the norms, languages, and cultures of communities and families.
- Any person conducting screening and involved with the screening process should be qualified and appropriately trained.
Caregiver/Family Screening Tools
Consider utilizing the tool, Screening, Brief Intervention, and Referral to Treatment (SBIRT) to screen family members if appropriate. The SBIRT is an evidence-based tool recommended by SAMHSA. SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use/mental health disorders, as well as those who are at risk of developing these disorders.
SBIRT is not included in the service components of HBFT L1 but can be reimbursed through the State Plan regulations when performed by a community behavioral health services provider.
The SBIRT can be implemented through self-report questionnaires, structured interviews, or similar screening techniques to detect substance use problems and to identify the appropriate level of intervention. If the screening is positive for substance use problems, the provider may provide brief intervention services that involve motivational discussion focused on raising the recipient’s awareness of their substance use, the potential harmful effects of that substance use, and encouraging positive change.
Brief intervention services may include:
(1) feedback;
(2) goal setting;
(3) coping strategies;
(4) identification of risk factors;
(5) information; and
(6) advice.
If the SBIRT indicates the recipient is at risk of behavioral health problems, is substance dependent, or has already received brief intervention or treatment for behavioral health and was non-responsive, the provider refers the recipient to treatment.
Delivery of screening and brief intervention services does not require an intake assessment or behavioral health treatment plan but does need to be documented in a progress note.
See Attachment B for the SBIRT form. The Drug Abuse Screening Test, DAST-10, can also be utilized (Attachment C).
Attachment D identifies substance use treatment providers in Alaska. For treatment resources for behavioral health services, go to Alaska Community Mental Health Centers.
Practical Guide for HBFT L1 Service Delivery
Family Service Plans
HBFT L1 services must be according to a family services plan (FSP) developed by the provider in collaboration with the family. The FSP must include risk factors for any other natural supports in the home and out-of-home placement, along with any risk factors related to the development of substance use and/or mental health disorder.
If the youth being served does have a treatment plan, consider integrating the FSP into the existing treatment plan.
If the youth being served does not have a treatment plan, you will likely have to develop your own FSP form.
Suggested components for developing the FSP:
- Referral Source
- Reason for Referral
- Screening Results
- Family Demographics
- Persons Living in the Home
- Client and Family Health History
- Client and Family Behavioral Health History
- Client and Family Relationships
- Discipline Methods
- Family Strengths/Challenges
- Current or Past Legal Issues
- OCS or DJJ involvement
- Education/School Issues
- Community Issues
- Resources Needed
- Plan of Care (include goal statements and strategies to assist the family to achieve goals)
Once the FSP is developed with the family, you are ready to start providing the service components as identified earlier on. You are required to document services provided in a progress note.
Clinical Flow
The clinical flow of HBTL1 services follows the same as in the provision of behavioral health treatment, including:
- Referral Information
- Screening Results
- Intake Information
- Family Service Plan (updated as necessary)
- Progress Notes (addressing the goals and strategies outlined in the FSP)
- Discharge Information
Documentation
Utilize your organization’s current policies and procedures (P&P) for clinical documentation. You may need to revise your P&Ps to accommodate HBTL1 requirements. Documentation may be paper or electronic. For organizations utilizing AKAIMS (Alaska Automated Information Management System), please refer to Attachment E for suggested step-by-step instructions.
Coding/Billing
Utilize your existing billing processes. HBFT L1 is provided under the code H1011 V2. Location codes are: 12-Home; 04-Homeless Shelter; 99-Other, appropriate setting in community (e.g., work, school, visitation office).
This service reimburses $24.16 for each 15-minute unit. Programs may employ a multidisciplinary team of professionals to work in their HBFT L1 program(s). Each CBHS is encouraged to determine cost efficiency to determine staffing.
The code for the SBIRT is 99408. A typical episode of care is between 15-30 minutes and gets reimbursed at 42.61 per episode.
Service Limitations
HBFT L1 – A maximum of 40 units per week for 6 weeks in the state fiscal year. Service authorizations will be needed to this extend limit effective pending adoption of the current 1115 services waiver regulation package or May 11, 2024, whichever is sooner. For more information on Service Authorizations, go to Optum Alaska – Forms.
Until the time that service authorizations go into effect, you are encouraged to update your FSPs prior to their expiration to ensure ongoing medical necessity for the HBFT L1 services you provide.
SBIRT – This service is limited to one episode per day. There are no annual limits.