Addition of Assertive Community Treatment Services
Effective July 1, 2023, the South Carolina Department of Health and Human Services (SCDHHS) will cover Assertive Community Treatment (ACT) services through the Medicaid State Plan. The Rehabilitative Behavioral Health Services (RBHS) manual will be updated by July 1, 2023, to reflect the addition of these services.
ACT uses a team treatment approach designed to provide comprehensive, community-based behavioral health treatment, rehabilitation, and support to persons with serious and persistent mental illness. Through this team approach, ACT services will help improve coordination of care. Through this model, providers will be reimbursed an all-inclusive daily rate for rendering services to Healthy Connections Medicaid members that may be currently receiving services that are billed as standalone RBHS services; utilizing the daily rate for ACT services precludes billing for any other behavioral health service.
ACT services are provided by a multidisciplinary team that must include the following types of providers:
- Psychiatric care provider (psychiatrist, advanced practice registered nurse [APRN], nurse practitioner [NP], physician assistant [PA]);
- ACT team leader — a qualified mental health professional (QMHP) with independent licensure (licensed independent social worker-clinical practice [LISW-CP], licensed professional counselor [LPC], licensed marriage and family therapist [LMFT], or licensed psychologist);
- Registered nurse (RN);
- Co-occurring disorder professional — a master’s level licensed or certified addictions counselor;
- Certified peer support specialist (South Carolina certification);
- Vocational success specialist —must have a minimum of a bachelor’s degree in a human services field, at least one year experience working with adults with serious mental illness, and at least six months experience providing employment or educational support;
- Mental health professional —must have a bachelor’s degree in a human services field and one year experience working with the population served, or a master’s degree in social work, counseling, psychology, or related field; and,
- Administrative assistant.
ACT teams provide in vivo, flexible service delivery in the person’s environment, and are available for crisis management 24 hours per day, seven days per week. Additional guidance on how ACT teams must demonstrate 24-hour provision of crisis management services and flexible service delivery will be available in the RBHS provider manual.
Within the first two years of service provision, ACT teams are expected to become certified as determined by fidelity to the Tool for Measurement of Assertive Community Treatment (TMACT). Benchmarks for fidelity include verification of the multidisciplinary team mentioned above, a staff to patient ratio of no higher than 1:10 and appropriate program size. Providers are advised that the psychiatric care provider and administrative assistant are not included when calculating the staff to patient ratio. Baseline fidelity audits of ACT teams will be conducted no later than Jan. 31, 2024. Additional information on the levels of fidelity and the requirements will be available in the RBHS provider manual.
Prior Authorization, Concurrent Review Requirements and Continuity of Care
ACT services require prior authorization and concurrent reviews to ensure medical necessity. However, to provide continuity of care for members currently receiving ACT-like services (billed as standalone RBHS services), up to 180 days will be allowed for providers and payment entities to transition to prior authorization for ACT services. After Dec. 29, 2023, the transition period will end and prior authorization will be required. Prior authorization must include a recommendation for ACT services by a physician, NP, PA or licensed psychologist. Prior authorization submission information for Healthy Connections Medicaid members enrolled in the fee-for-service (FFS) program and those enrolled in a managed care organization (MCO) is available below.
- For Healthy Connections Medicaid members enrolled in the FFS program, prior authorizations will be issued by SCDHHS’ contracted quality improvement organization (QIO), KEPROF. Providers with questions about prior authorizations for members enrolled in the FFS Medicaid program can contact KEPRO by phone at +1 (855) 326-5219 or email at email@example.com. Providers can also submit documents to KEPRO by fax at +1 (855) 300-0082.
- For members enrolled in an MCO, prior authorizations will be issued by the member’s MCO. MCO’s prior authorization phone numbers are available here on SCDHHS’ website.
During the 180-day transition period, members currently receiving ACT-like services will be reviewed to determine eligibility for continuing ACT services.
Concurrent reviews are required to confirm ongoing medical necessity and appropriate level of service provision. Concurrent reviews must be completed no sooner than six months after service initiation (and every subsequent six months thereafter) for continued review of level of service provision and medical necessity.
Rates for ACT Services
ACT services will be paid through daily rates designated for both small teams (50 clients or less) and large teams (51 to 129 clients):
|Team Size||Daily Rate Per Medicaid Member|
|Small Teams (50 or less)||$175.65|
|Large Teams (51-129)||$157.75|
On July 31, 2023, SCDHHS will host training conducted by the University of North Carolina ACT Technical Assistance Center related to ACT services and fidelity measures. Information about the training will be provided in an upcoming Medicaid bulletin.
Providers should direct questions related to this bulletin to the Provider Service Center (PSC) at: (888) 289-0709 or to firstname.lastname@example.org. The PSC’s hours of operations are 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday.