PMA 10.1.5
PRIOR AUTHORIZATION CRITERIA
FOR ADMISSION AND CONTINUED STAY FOR HCTC
A. PURPOSE
Home Care Training to Home Care Clients (HCTC) services are specific behavioral health services provided in a
home setting by a DES-licensed professional foster care home. HCTC includes 24 hour supervision and the
provision of behavioral health support services including psychosocial rehabilitation, skills training and
development and transportation of members, when necessary, to activities such as therapy and visitations.
HCTC providers are expected to participate in treatment and discharge planning, as well as in identified
educational services and/or staffings. At times, HCTC services are not sufficient to meet a member’s needs and
may require augmentation with medically necessary behavioral health outpatient services to assist the member
in achieving his/her discharge goals.
An active treatment plan aims to return the member to his/her customary environment at the earliest possible
time. The HCTC treatment goals must be focused on the signs and symptoms of the psychiatric disorder which
necessitated the member’s removal from his/her usual living situation. These treatment goals must be defined
prior to admission. It is not expected that all behavioral or psychological difficulties will be resolved by the time
of discharge from an HCTC home. Individuals referred for primary substance abuse treatment are exempt from
the prior authorization criteria listed below.
A tentative discharge plan also must be outlined prior to admission. Child and Family Team (CFT) facilitators are
expected to explain to CFT members that HCTC cannot be used as permanent housing as that would violate
Medicaid regulations for “medically necessary” services. The CFT must develop a viable and realistic
permanency plan with a specifically identified living arrangement that is included in the discharge plan submitted
in the request for HCTC funding.
Admissions to HCTC homes are not emergent or urgent and always require prior authorization. A lack of
available outpatient services is not, in and of itself, the sole criterion for admission to an HCTC home.
A decision to prior authorize admission into an HCTC home will be made within 14 business days. Prior
authorization for initial admission for HCTC is valid for up to 90 days, and re-authorization for continued stay is
valid for up to 90 days.
B. CRITERIA REQUIRED FOR ADMISSION
All of the following are required:
1) The member presents with signs and symptoms of a psychiatric disorder which is consistent with a current DSM
diagnosis (or the corresponding ICD diagnosis).
a) Runaway behavior is an insufficient justification for admission to any level of out of home treatment as an
isolated behavior.
2) The symptom or behavior which is the focus of treatment results in at least moderate functional impairment of
developmentally appropriate self-care or self-regulation as evidenced by:
a) Documentation of recent occurrence(s) of suicidal or homicidal ideation without plan or intent, and
the inability of the member and support system to carry out a safety plan; or
b) Documentation of a disturbance of mood thought or behavior that clearly impairs daily functioning,
persists in the absence of stressors, and impairs recovery from the presenting problem.
3) Any present medical condition can be safely managed within the HCTC setting.
4) Medically necessary outpatient behavioral health services do not meet the treatment needs of the member and
there is documentation of a failure to respond or an inability to be safely managed in a less restrictive level of care.
5) The medically necessary behavioral health treatment can be properly provided within a HCTC setting.
6) The admission is not used primarily and therefore clinically inappropriately as:
a) An alternative to detention, incarceration or as a means to ensure community safety in a member
exhibiting primarily delinquent/antisocial behavior; or
b) The equivalent of safe housing, permanent placement, or
c) An alternative to parents’/guardians’ or other agencies’ capacity to provide for the member, or
d) A behavioral health intervention when other less restrictive alternatives are available and meet the
member’s treatment needs.
7) A preliminary discharge plan of aftercare services and supports has been developed and presented
with the request for prior authorization.
PMA 10.1.5
Effective 10/1/2015
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Revised 12/11/2015
C. CONTINUED STAY CRITERIA
There is documented evidence of all of the following:
1) Active treatment and supervision is being provided by the HCTC home on a 24 hour basis with direct
supervision/oversight by professional behavioral health staff; and
2) The treatment is reducing the severity of the behavioral health issue that was identified as the reason
for admission; and
3) The Child and Family Team has met every 4 weeks or more frequently, if clinically indicated, to review
progress and revise the service plan to address any lack of progress; and
4) There is an expectation that continued treatment can reasonably be expected to improve or stabilize the
member’s condition so that this type of service will no longer be needed.
D. DISCHARGE CRITERIA
To be considered for discharge from the HCTC setting, the following criteria are met:
1) There is a written plan with specific discharge criteria, written as behaviorally measurable goals.
2) There is documentation that the Child and Family Team is involved in the writing of the discharge plan.
3) The plan complies with current standards for medically necessary covered behavioral health services, cost
effectiveness, and least restrictive environment and is in conformation with federal and state clinical
practice guidelines.
4) The member’s treatment plan goals, as identified at admission to this level of care, have been accomplished;
OR the member is not making progress toward treatment goals and there is no reasonable expectation of
progress at this level of care.
PMA 10.1.5
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