MassHealth Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Medical Necessity Criteria Therapeutic Mentoring Services Therapeutic Mentoring Services are provided to youth (under the age of 21) in any setting where the youth resides, such as the home (including foster homes and therapeutic foster homes), and other community settings such as a school, child care centers, respite settings, and other culturally and linguistically appropriate community settings. Therapeutic Mentoring offers structured, one-to-one, strength-based support services between a therapeutic mentor and a youth for the purpose of addressing daily living, social, and communication needs. Therapeutic Mentoring services include supporting, coaching, and training the youth in age- appropriate behaviors, interpersonal communication, functional skill-building, problem- solving and conflict resolution, and relating appropriately to other youth, as well as adults, in recreational and social activities pursuant to a behavioral health treatment plan developed by an outpatient, or In-Home Therapy provider in concert with the family, and youth whenever possible, or Individual Care Plan (ICP) for youth in ICC. These services help to ensure the youth’s success in navigating various social contexts, learning new skills and making functional progress, while the therapeutic mentor offers supervision of these interactions and engages the youth in discussions about strategies for effective handling of peer interactions. Therapeutic Mentoring services must be necessary to achieve a goal(s) established in an existing behavioral health treatment plan for outpatient or In-home Therapy or in an ICP for youth in ICC, and progress toward meeting the identified goal(s) must be documented and reported regularly to the youth’s current treater(s). Services are designed to support age- appropriate social functioning or ameliorate deficits in the youth’s age-appropriate social functioning. Criteria Admission Criteria All of the following are necessary for admission to this level of care. 1. A comprehensive behavioral health assessment inclusive of the MA Child and Adolescent Needs and Strengths (CANS) indicates that the youth’s clinical condition warrants this service in order to support age-appropriate social functioning or ameliorate deficits in the youth’s age-appropriate social functioning. If the member has MassHealth as a secondary insurance and is being referred to services by a provider who is paid through the member’s primary insurance, the provider must conduct a comprehensive behavioral health assessment. A CANS is not required. Admission Criteria (cont.) 2. The youth requires education, support, coaching, and guidance in age-appropriate behaviors, interpersonal communication, problem-solving and conflict resolution, and relating appropriately to others to address daily living, social, and communication needs and to support the youth in a home, foster home, or community setting, or, the youth may be at risk for out-of-home placement as a result of the youth’s mental health condition, or, requires support in transitioning back to the home, foster home, or community from a congregate care setting. 3. Outpatient services alone are not sufficient to meet the youth’s needs for coaching, support, and education. 4. Required consent is obtained. 5. The youth is currently engaged in outpatient services, In-Home Therapy or ICC and the provider or ICC CPT, determine that Therapeutic Mentoring Services can facilitate the attainment of a goal or objective identified in the treatment plan or ICP that pertains to the development of communication skills, social skills and peer relationships. Psychosocial, Occupational, and Cultural and Linguistic Factors These factors may change the risk assessment and should be considered when making level-of-care decisions. Exclusion Criteria Any one of the following criteria is sufficient for exclusion from this level of care. 1. The youth displays a pattern of behavior that may pose an imminent risk to harm self or others, or sufficient impairment exists that requires a more intensive service beyond community-based intervention. 2. The youth has medical conditions or impairments that would prevent beneficial utilization of services. 3. Therapeutic Mentoring services are not needed to achieve an identified treatment goal. 4. The youth’s primary need is only for observation or for management during sport/physical activity, school, after-school activities, or recreation, or for parental respite. 5. The service needs identified in the treatment plan/ICP are being fully met by similar services. 6. The youth is placed in a residential treatment setting with no plans for return to the home setting. Continued Stay Criteria All of the following criteria are required for continuing treatment at this level of care. 1. The youth’s clinical condition continues to warrant Therapeutic Mentoring Services in order to continue progress toward treatment plan goals. 2. The youth’s treatment does not require a more intensive level of care. 3. No less intensive level of care would be appropriate. 4. Care is rendered in a clinically appropriate manner and focused on the youth’s behavioral and functional outcomes as described in the treatment plan/ICP. 5. Progress in relation to specific behavior, symptoms, or impairments is evident and can be described in objective terms, but goals have not yet been achieved, or adjustments in the treatment plan/ICP to address lack of progress are evident. 6. The youth is actively participating in the plan of care to the extent possible consistent with his/her condition. 7. Where applicable, the parent/guardian/caregiver and/or natural supports are actively involved as required by the treatment plan/ICP. Discharge Criteria Any one of the following criteria is sufficient for discharge from this level of care. 1. The youth no longer meets admission criteria for this level of care, or meets criteria for a less or more intensive level of care. 2. The treatment plan/ICP goals and objectives have been substantially met and continued services are not necessary to prevent worsening of the youth’s behavioral health condition. 3. The youth and parent/guardian/caregiver are not engaged in treatment. Despite multiple, documented attempts to address engagement, the lack of engagement is of such a degree that it implies withdrawn consent or treatment at this level of care becomes ineffective or unsafe. 4. Required consent for treatment is withdrawn. 5. The youth is not making progress toward treatment goals, and there is no reasonable expectation of progress at this level of care, nor is it required to maintain the current level of functioning. Discharge Criteria (cont.) 6. The youth is placed in a hospital, skilled nursing facility, psychiatric residential treatment facility, or other residential treatment setting and is not ready for discharge to a family home environment or a community setting with community- based supports. MNC-TMS (Rev. 07/12)