UPDATE: 5/16/19
This if from the Michigan Medicaid Provider Manual and applies to all Medicaid services for people with developmental and other disabilities. PIHPs (Prepaid Inpatient Health Plans) are the regional mental health agencies in Michigan. Take note of the last paragraph [UPDATED on 4/1/19]:
A PIHP may not deny services based solely on preset limits of the cost, amount, scope, and duration of services. Instead, determination of the need for services shall be conducted on an individualized basis. [This wording has the same meaning as it did in previous versions of the Medicaid Provider Manual, but it is a little more concise.]
The following medical necessity criteria apply to Medicaid mental health, developmental disabilities, and substance abuse supports and services
Medical Necessity Criteria
Mental health, developmental disabilities, and substance abuse services and treatment:
- Necessary for screening and assessing the presence of a mental illness, developmental disability or substance use disorder; and/or
- Required to identify and evaluate a mental illness, developmental disability or substance use disorder; and /or
- Intended to treat, ameliorate, diminish, or stabilize the symptoms of mental illness, developmental disability or substance use disorder; and/ or
- Expected to arrest or delay to progression of a mental illness, developmental disability or substance use disorder; and/ or
- Designed to assist the beneficiary to attain or maintain a sufficient level of functioning in order to achieve his goals of community inclusion and participation, independence, recovery, or productivity.
The determination of a medically necessary support, service or treatment must be:
- Based on information provided by the beneficiary, beneficiary’s family, and/ or other individual’s (e.g., friends, personal assistants/ aides) who know the beneficiary;
- Based on clinical information from the beneficiary’s primary care physician or health care professionals with relevant qualifications who have evaluated the beneficiary;
- For beneficiaries with mental illness or developmental disabilities, based on person-centered planning, and for beneficiaries with substance use disorders, individualized treatment planning;
- Made by appropriately trained mental health, developmental disabilities, or substance abuse professional with sufficient clinical experience;
- Made within federal and state standards for timeliness;
- Sufficient in amount, scope and duration of service(s) to reasonably achieve its/ their purpose; and
- Documented in the individual plan of service.
Supports, Services, and Treatment Authorized by the PIHP must be:
- Delivered in accordance with federal and state standards for timeliness in a location that is accessible to the beneficiary;
- Responsive to particular needs of multi-cultural populations and furnished in a culturally relevant manner;
- Responsive to the particular needs of beneficiaries with sensory or mobility impairments and provided with the necessary accommodations;
- Provided in the least restrictive, most intergrated setting. Inpatient, licensed residential or other segregated settings shall be used only when less restrictive levels of treatment, service or support have been, for that beneficiary, unsuccessful or cannot be safely provided; and
- Delivered consistent with, where they exist, available research findings, health care practice guidelines, best practices and standards of practice issued by professionally recognized organizations or government agencies.
PIHP Decisions:
Using criteria for medical necessity, a PIHP may:
Deny services that are:
- Deemed ineffective for a given condition based upon professionally and scientifically recognized and accepted standards of care;
- Experimental or investigational in nature; or
- For which there exists another appropriate, efficacious, less -restrictive and cost-effective service, setting or support that otherwise satisfies the standards for medically-necessary services; and/ or
- Employ various methods to determine amount, scope and duration of services, including prior authorization for certain services, concurrent utilization reviews, centralized assessment and referral, gate-keeping arrangements, protocols, and guidelines.
A PIHP may not deny services based solely on preset limits of the cost, amount, scope, and duration of services. Instead, determination of the need for services shall be conducted on an individualized basis. [updated in the Medicaid Provider Manual on 4/1/19]
