Sec.17a-453a-4. Covered behavioral health services

The following behavioral health services shall be covered behavioral health services within the GABHP:

(1) Acute psychiatric hospitalization: A medically necessary, inpatient behavioral health service delivered in a private freestanding psychiatric hospital, general hospital or state-operated facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to treatment of a psychiatric disability or co-occurring disorder, where an individual's admission is the result of a serious or dangerous condition that requires rapid stabilization of psychiatric symptoms. Acute psychiatric hospitalization is used when 24-hour medical and nursing supervision are required to deliver intensive evaluation, medication titration, symptom stabilization and intensive, brief treatment. Acute psychiatric hospitalization may be delivered to individuals committed under a Physician's Emergency Certificate (PEC), pursuant to section 17a-502 of the Connecticut General Statutes, and may occur on a locked psychiatric unit;

(2) Ambulatory detoxification: A medically necessary, non-residential behavioral health service delivered in a private freestanding psychiatric hospital, general hospital, state-operated facility or other facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to ambulatory chemical detoxification. Ambulatory detoxification uses prescribed medication to alleviate physical or psychological effects experienced by an individual as a result of withdrawal from a specific psychoactive substance and shall be delivered only after an evaluation has been conducted and a determination has been made that the individual is medically able to tolerate an outpatient detoxification. Ambulatory detoxification shall involve an assessment of needs, including those related to recovery supports and motivation of the individual regarding his or her continuing participation in the treatment process. Individuals shall receive a minimum of one (1) hour per week of substance use disorders services;

(3) Ambulatory detoxification with on-site monitoring: A medically necessary, non-residential behavioral health service delivered in a private freestanding psychiatric hospital, general hospital, state-operated facility or other facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to ambulatory chemical detoxification. Ambulatory detoxification with on-site monitoring shall deliver psychiatric and other behavioral health services that address the individual's problems as identified through a comprehensive biopsychosocial assessment. Ambulatory detoxification with on-site monitoring uses prescribed medication to alleviate physical or psychological effects experienced by an individual as a result of withdrawal from a specific psychoactive substance and shall be delivered only after an evaluation has been conducted and a determination has been made that the individual is medically able to tolerate an outpatient detoxification. Ambulatory detoxification with on-site monitoring shall involve an assessment of individual needs, including those related to recovery supports and motivation of the individual regarding his or her continuing participation in the treatment process. Individuals shall receive a minimum of one (1) hour of substance use disorders services per week;

(4) Chemical maintenance treatment: A medically necessary, non-residential behavioral health service delivered in a facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to chemical maintenance treatment. Chemical maintenance treatment involves regularly scheduled administration of SAMHSA-approved medication, prescribed at individual dosages and shall include a minimum of one (1) clinical contact per month. More frequent clinical contacts shall be delivered if indicated in the individual's recovery plan;

(5) Initial intake evaluation: The first evaluation of an individual to determine whether it is medically necessary for the individual to be admitted to a covered behavioral health service;

(6) Intensive outpatient-mental health: A medically necessary, non-residential behavioral health service delivered in a private freestanding psychiatric hospital, general hospital, a state-operated facility or other facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to psychiatric outpatient services for adults. Each individual shall receive three (3) to four (4) hours per day, three (3) to five (5) days per week (i.e., a minimum of nine (9) hours per week) of individualized treatment that includes at least one (1) individual or group therapy session per day. Treatment shall focus on reducing symptoms, improving functioning, maintaining the individual in the community, preventing relapse and reducing the likelihood that care may be required in a more restrictive setting;

(7) Intensive outpatient-substance use: A medically necessary, non-residential behavioral health service delivered in a private freestanding psychiatric hospital, general hospital, state-operated facility or other facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to intensive outpatient-substance use services. Each individual shall receive three (3) to four (4) hours per day, three (3) to five (5) days per week (i.e., a minimum of nine (9) hours per week) of individualized treatment that includes at least one (1) individual or group therapy session per day. Treatment shall focus on relapse prevention and the individual's ability to manage his or her recovery;

(8) Intensive residential treatment: A medically necessary, residential behavioral health service delivered in a private freestanding psychiatric hospital, general hospital, state-operated facility or other facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations. Intensive residential treatment shall be delivered in a 24-hour setting to treat individuals with substance use disorders who require an intensive rehabilitation program. Intensive residential treatment is delivered within a fifteen (15) to thirty (30) day period and includes a minimum of thirty (30) hours of substance use disorder services per week;

(9) Intermediate or long-term treatment or care: A medically necessary, residential behavioral health service delivered in a facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to intermediate or long-term treatment or care and rehabilitation. Each individual shall receive substance use disorder services to address significant problems with his or her behavior and functioning in major life areas due to a substance use disorder and to reintegrate such individual into the community. Intermediate or long-term treatment or care shall be delivered in a structured recovery environment and shall comply with the following applicable requirements:

(A) If the facility is licensed for and delivers intermediate or long-term residential treatment, a minimum of twenty (20) hours per week of substance use disorder services shall be delivered to each individual;

(B) If the facility is licensed for care and rehabilitation and delivers long-term care, a minimum of twenty (20) hours of substance use disorder services shall be delivered to each individual per week; and

(C) If the facility is licensed for intermediate or long-term residential treatment and delivers transitional or halfway-house services, a minimum of four (4) hours per week of substance use disorder services shall be delivered to each individual;

(10) Laboratory services: Specimen testing and analysis used to establish the diagnosis and treatment of behavioral health disorders and delivered by a facility that is:

(A) Certified pursuant to the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 CFR 943; and

(B) Licensed by DPH as a clinical laboratory pursuant to section 19a-30 of the Connecticut General Statutes;

(11) Matrix intensive outpatient: A medically necessary, non-residential, evidence-based, sixteen (16) week individualized behavioral health service that is delivered in a facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to outpatient treatment. Matrix intensive outpatient is designed to give individuals with substance use disorders the knowledge, structure, and support to enable them to achieve abstinence from substances and initiate recovery;

(12) Medically managed inpatient detoxification: A medically necessary, inpatient behavioral health service delivered in a private freestanding psychiatric hospital, state-operated facility or general hospital that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to the treatment of substance use disorders, where the individual's admission is the result of a serious or dangerous condition that requires rapid treatment for a substance use disorder. Medically managed inpatient detoxification is used when on-site, 24-hour medical and nursing supervision are required to deliver intensive evaluation, medication titration, symptom stabilization and intensive, brief treatment. Medically managed inpatient detoxification shall deliver evaluation for substance use disorders and withdrawal management. For individuals who have co-occurring disorders, psychiatric assessment and management shall be available. Medically managed inpatient detoxification may be delivered to patients committed under a Physician's Emergency Certificate (PEC), pursuant to section 17a-684 of the Connecticut General Statutes;

(13) Medically monitored residential detoxification: A medically necessary, inpatient behavioral health service delivered in a state-operated facility or in a facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to residential detoxification and evaluation that involves treatment of a substance use disorder. Medically monitored residential detoxification shall be used when 24-hour medical and nursing supervision are required. Medically monitored residential detoxification shall deliver 24-hour substance use evaluation and withdrawal management;

(14) Observation bed-mental health: A medically necessary, inpatient behavioral health service delivered in a private freestanding psychiatric hospital, state-operated facility or general hospital that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to supervised stabilization, clinical monitoring and, when necessary, laboratory testing to facilitate the formulation of an appropriate diagnosis and suitable treatment of an individual who is in urgent need of care and treatment for a psychiatric disability. Observation beds may be used for no more than twenty-three (23) hours before discharge or transfer to another level of care is required;

(15) Observation bed-substance use: A medically necessary, inpatient behavioral health service delivered in a private freestanding psychiatric hospital, general hospital, state-operated facility or residential detoxification facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to supervised stabilization, clinical monitoring and, when necessary, laboratory testing to facilitate the formulation of an appropriate diagnosis and suitable treatment program for an individual who is in urgent need of care and treatment for a substance use disorder. Observation beds may be used for no more than twenty-three (23) hours before discharge or transfer to another level of care is required;

(16) Outpatient-mental health: A medically necessary, non-residential behavioral health service delivered in a general hospital, psychiatric outpatient clinic for individuals, private freestanding psychiatric hospital, state-operated facility or other facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to the evaluation, diagnosis and treatment of individuals;

(17) Outpatient-substance use: A medically necessary, non-residential behavioral health service delivered in a private freestanding psychiatric hospital, general hospital, state-operated facility or other facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to outpatient treatment that includes, but is not limited to, professionally directed evaluation, treatment and recovery support activities that shall be delivered in regularly scheduled sessions, usually weekly, but no less frequently than every thirty (30) days;

(18) Partial hospitalization-mental health: A medically necessary, non-residential behavioral health service delivered in a general hospital, private freestanding psychiatric hospital, state-operated facility or private freestanding mental health day treatment facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to intensive psychiatric treatment services. Partial hospitalization-mental health shall deliver to each individual a minimum of four (4) hours per day, three (3) to five (5) days per week (i.e., a minimum of twelve (12) hours per week) of individualized treatment based on a recovery plan that includes at least one (1) individual or group session per day. Partial hospitalization-mental health may be delivered on a day, evening or weekend schedule. Partial hospitalization-mental health is designed to serve individuals with significant impairments resulting from psychiatric disabilities to avert hospitalization, thereby increasing an individual's level of independent functioning; and

(19) Partial hospitalization-substance use: A medically necessary, non-residential behavioral health service delivered in a general hospital, private freestanding psychiatric hospital, state-operated facility or other facility that meets and maintains all applicable licensing and certification requirements of federal and state statutes or regulations pertaining to day or evening treatment that includes, but is not limited to, access to psychiatric, medical and laboratory services for individuals recently discharged from an inpatient facility or whose admission to inpatient care might be averted by treatment in a day or evening program. Partial hospitalization-substance use delivers to each individual a minimum of four (4) hours per day, three (3) to five (5) days per week (i.e., a minimum of twelve (12) hours per week) of substance use disorder services, based on an individualized recovery plan that includes at least one individual or group therapy session per day.

(Adopted effective December 7, 2009)