(1) The therapeutic portion of medically necessary therapeutic family care treatment is covered for recipients with a primary diagnosis of severe emotional disturbance (SED) as defined in ARM 37.86.3702, or with both an emotional disturbance and a developmental disability, if the treatment is ordered by a licensed physician, licensed psychologist, masters level licensed clinical social worker (MSW) or a licensed professional counselor (LPC) , and prior-authorized by the department or its designee according to the provisions of ARM 37.88.101.

(a) The therapeutic portion of moderate level therapeutic family care treatment, as defined in ARM Title 37, chapters 37 and 97, is covered if provided by a therapeutic family care agency licensed by and contracted with the department to provide moderate level therapeutic family care service.

(b) The therapeutic portion of permanency therapeutic family care treatment, as defined in (2) (c) (i) , is covered if provided by a therapeutic family care agency licensed by and contracted with the department to provide intensive therapeutic family care services.

(i) Permanency therapeutic family care treatment is intensive level therapeutic family care treatment for which the foster family placement is permanent and which includes:

(A) individual, family and group therapies;

(B) clinical supervision provided by a licensed psychologist on a 1:20 ratio;

(C) a treatment manager who is a masters or bachelors level social worker with three years experience, on a 1:6 ratio;

(D) therapeutic aide services averaging at least ten hours per week;

(E) respite care at least one weekend per month; and

(F) additional specialized training for families.

(c) Medicaid will not reimburse for room, board, maintenance or any other nontherapeutic component of therapeutic family care treatment.

(2) Medicaid reimbursement is not available for therapeutic youth family care services unless the provider submits to the department or its designee in accordance with these rules a complete and accurate certificate of need that certifies the necessary level of care. A child or adolescent must meet at least four of the following criteria for moderate therapeutic family care treatment services:

(a) Symptoms of the individual's emotional disturbance or mental illness are of a severe or persistent nature requiring more intensive treatment and clinical supervision than can be provided by outpatient mental health service.

(b) The beneficiary exhibits behaviors related to the covered diagnosis that result in significant risk that the beneficiary will require psychiatric hospitalization or placement in a more restrictive environment if therapeutic living care is not provided or the beneficiary is currently being treated or maintained in a more restrictive environment and requires a structured treatment environment in order to be successfully treated in a less restrictive setting.

(c) The prognosis for treatment of the individual's mental illness or emotional disturbance at a less restrictive level of care is very poor because the individual demonstrates three or more of the following due to the emotional disturbance or mental illness:

(i) significantly impaired interpersonal or social functioning;

(ii) significantly impaired educational or occupational functioning;

(iii) impairment of judgment; or

(iv) poor impulse control.

(d) As a result of the emotional disturbance or mental illness, the individual exhibits an inability to perform daily living activities in a developmentally appropriate manner.

(e) As a result of the emotional disturbance or mental illness, the beneficiary exhibits maladaptive or disruptive behavior that is developmentally inappropriate.

(3) Providers of therapeutic family care treatment services are required to abide by the revised guidelines adopted in ARM 37.86.2219.

(4) For recipients determined Medicaid eligible by the department as of the time of admission to the therapeutic youth family care, the certificate of need required under (2) must be:

(a) completed, signed and dated prior to, but no more than 30 days before, admission; and

(b) made by a team of health care professionals that has competence in diagnosis and treatment of mental illness and that has knowledge of the recipient's situation, including the recipient's psychiatric condition. The team must include a physician that has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, and a licensed mental health professional. No more than one member of the team of health care professionals may be professionally or financially associated with a therapeutic family care program.

(5) For recipients determined Medicaid eligible by the department after admission to or discharge from the therapeutic youth family care, the certificate of need required under (2) is waived. A retrospective review to determine the medical necessity of the admission to the program and the treatment provided will be completed by the department or its designees at the request of the department, a provider, the individual or the individual's parent or guardian. Request for retrospective review must be:

(a) received within 14 days after the eligibility determination for recipients determined eligible following admission, but before discharge from therapeutic youth family care; or

(b) received 90 days after the eligibility determination for recipients determined eligible after discharge from therapeutic youth family care.

(6) All certificates of need required under (2) must actually and personally be signed by each team member, except that signature stamps may be used if the team member actually and personally initials the document over the signature stamp.