This section establishes Medicaid payment policy for Intensive Behavioral Health Services (IBHS) agencies in Pennsylvania, covering payment conditions for licensed and unlicensed IBHS providers, including transitional payment periods for agencies previously licensed under outpatient psychiatric clinic, psychiatric partial hospitalization, or family-based mental health licenses, as well as those approved for ABA services. Providers must comply with Chapter 5240 (IBHS regulations), general MA program provisions, and third-party resource requirements. Payment is contingent on medical necessity and supervision by a qualified clinical director.
View official source55 Pa. Code § 1155.31 - General payment policy State Regulations Compare (a) Except as provided in subsections (b)-(d), payment is made to a licensed IBHS agency for medically necessary IBHS provided by qualified individuals under the supervision and direction of a clinical director that meets the qualifications in § 5240.12 (b) or § 5240.81 (b) (relating to staff qualifications; and staff qualifications for ABA services), subject to the conditions and limitations in this chapter, Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule. (b) Payment will be made to an IBHS agency that complies with Chapter 5240 (relating to intensive behavioral health services) and holds an outpatient psychiatric clinic, a psychiatric partial hospitalization program or a family-based mental health license issued by the Department as of October 19, 2019, until the agency's license expires. (c) Payment will be made to an unlicensed IBHS agency that complies with Chapter 5240 and is approved to provide behavioral health rehabilitation services as of October 19, 2019, for 1 year after promulgation of this chapter. (d) Payment will be made to an unlicensed IBHS agency that complies with Chapter 5240 and is approved to provide ABA services as of October 19, 2019, for 180 days after promulgation of this chapter. (e) Payment will not be made for a compensable IBHS if payment is available through a third party. Providers shall comply with § 1101.64 (relating to third-party medical resources (TPR)). Notes 55 Pa. Code § 1155.31 State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare. No prior version found. State Regulations Toolbox