Transcript Value Behavioral Health of Pennsylvania

Value Behavioral Health of
Pennsylvania
BHRS Consumer/Family Forum
Crawford, Mercer & Venango Counties
June 2007
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Pennsylvania HealthChoices
Program
•
State Medical Assistance (MA) Managed Care
Program
•
The HealthChoices Program has three main
goals
•
To improve access to healthcare services for
MA consumers
•
To improve the quality of care available to
MA consumers
•
To stabilize Pennsylvania’s MA spending
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Who is Value Behavioral
Health-PA (VBH-PA)??
• Value Behavioral Health-PA (VBH-PA)
is a managed care company
• VBH-PA is working with your county
to ensure the success of the
HealthChoices Program
• VBH-PA staff will be available to
answer your questions when you call
the toll-free member services number
established for your county
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The Benefits of HealthChoices
•
Supports the enhancement, expansion &
improvement of county-specific delivery of
services
•
Provides a continuum of in-plan and
supplemental services that promote
recovery and resiliency
Mental Health
• Substance Abuse
•
•
Provides consumers with a choice of innetwork providers
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Behavioral Health Services
Mental Health (MH)
•
•
•
•
•
Inpatient Psychiatric
Residential Treatment
Facilities (RTF) for
Children & Adolescents
MH Partial
Hospitalization
MH Outpatient
Behavioral Health
Rehabilitation Services
for
Children/Adolescents
(BHRS)
•Family-Based MH
•Intensive Case
Management (ICM)
•Resource Coordination
(RC)
•Blended Case
Management
(BCM)
•Certified Peer Specialist
•Crisis Intervention
•Clozapine Support
Services
•Laboratory Services
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Behavioral Health Services
Substance Abuse
Substance Abuse
•
Inpatient Drug & Alcohol (D&A)
Detoxification/Rehabilitation
•
Non-hospital Residential Detoxification/Rehabilitation
•
Halfway House
•
D&A Outpatient, including Intensive Outpatient (IOP)
•
Outpatient Narcotic Addiction Treatment
(Methadone Maintenance)
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Service Access
•
HealthChoices means you have a CHOICE of
providers
•
When members call VBH-PA for a referral,
they will be given at least two names of
providers to choose from
•
VBH-PA does not give recommendations, but
will offer members a choice of providers
•
VBH-PA clinicians will ask for information to
assess the need for services (emergency,
urgent, or routine)
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Service Access
There is no charge to you for
in-plan services that you receive.
•
HealthChoices members DO NOT pay for any covered
services they need. There is no co-pay. (This does not
include your prescriptions. Your prescriptions are paid
by your physical health plan.)
•
If members receive a bill, they should report this to
the VBH-PA Member Service Representative.
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Toll-Free Contact Numbers
VBH-PA Member Services
Erie
1-866-404-4560
NWBHP
1-866-404-4561
Cambria
1-866-404-4562
(Northwest Behavioral Health Partnership: Crawford, Mercer & Venango Counties)
Toll-Free Provider Line:
1-877-615-8503
TTY Telephone Number:
1-877-615-8502
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Member Benefits
•
All VBH-PA members are provided with a
Member Handbook that includes important
information on member benefits
•
Handbooks are mailed to all eligible
HealthChoices members in a bright pink
envelope
•
It is important to read and keep the
handbook
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Member Benefits
The Member Handbook includes:
•
A county-specific toll-free number to call with
any questions about behavioral health care
services and/or the HealthChoices program
•
Information on filing a complaint or grievance
•
Information on getting help in an emergency
•
Ways to share your opinions about your
services by taking a satisfaction survey
Member rights and responsibilities
•
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Learn about Your Rights
• As part of the HealthChoices Program, you
have the RIGHT to:
- Be treated with dignity and respect.
- Have your medical records and conversations with
people who give you care kept private.
- Take part in decisions about your care.
- Have your treatment plan explained to you.
- Help set up your treatment plan and ask for a change
to your treatment plan.
- Choose your provider from a list of HealthChoices
Program Providers.
- See your medical records and talk about them with
your provider.
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Learn about Your Rights
(continued)
Change your provider.
- Ask your provider about his or her qualifications or any
person who is helping you.
- Receive services without regard to race, color, religion, sex,
sexual orientation, age or ethnic background.
- Make a Complaint or file a Grievance about your care or the
services you receive.
- Talk with a Consumer Family Satisfaction Team (C/FST)
member about the quality of your services.
- Receive information on available treatment services.
- You have the right to be free from any form of restraint or
seclusion during your treatment that is used as a means of
coercion, discipline, convenience or retaliation.
- You have the right to create an Advanced Directive and share
it with your treatment provider.
-
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Learn about Your Rights
(continued)
- Have the side effects and risks of your medications explained to
-
-
-
-
you.
You may also request a copy of information maintained
by VBH-PA. The information may include claims
information, complaints, referrals, disclosures and other
documented contact you and your provider have had with
us.
You may request to amend (change) the VBH-PA
information listed above in order to correct any errors.
The decision to make a change is made by the VBH-PA
Medical Director.
You are free to exercise your rights. Exercising your
rights will not affect how you are treated by your
provider or by VBH-PA.
You have the right to request a second opinion about your
treatment.
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Learn about Your
Responsibilities
• As part of the HealthChoices program, you
have the RESPONSIBILITY to:
Respect the dignity and privacy of others.
- Give your provider the information that he or she needs
to better serve you.
- Work with your provider to help develop a treatment
plan and ask questions when you do not understand
your treatment.
- Try to follow the treatment plans you developed with your
provider.
- Keep your appointment with your provider.
-
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Learn about Your
Responsibilities (continued)
-
Contact your provider if you need to cancel or
re-schedule your appointment.
- Call the VBH-PA toll-free telephone number if you move
and/or change your address or phone number. If
you are hearing impaired, call the TTY number at
1-866-615-8502.
• Become familiar with your Rights and
Responsibilities. They are in your
Member Handbook.
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CASSP Principles
 Mental health services in Pennsylvania are
guided by the principles of the Child and
Adolescent Service System Program.
 Central to CASSP Principles is the
recognition that a child must be understood
in his or her natural context—the family,
the community and the child-serving
systems—not just individually.
 CASSP Principles are strengths-based and
treatment-focused.
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CASSP Principles






Child-centered
Family-focused
Community-based
Multi-system
Culturally competent
Least restrictive/least intrusive
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Evaluation
 Comprehensive Child and Adolescent
Strengths-Based Evaluation—Life Domain
 Best Practice format for initial evaluations
and re-evaluations
 Evaluation of the child’s strengths and
needs
 Review of past treatment trials and/or
review of treatment goals
 Consideration of the full continuum of care
 Documentation to support the medical
necessity of recommended level of care
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Independent Prescriber Model
 Prescribers who are credentialed by VBH-PA to
evaluate children/adolescents and make treatment
recommendations
 Criteria:
 Pennsylvania licensed psychiatrist, Pennsylvania
licensed psychologist or developmental
pediatrician
 Documented experience in evaluating children
and adolescents with special needs
 Satisfactory (85% or better) ratings on CCASBELD monitoring
 No affiliation with a BHRS/FBMH provider
 Panel of providers will be recruited for each county
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Interagency Service Planning
Team (ISPT)
 Functions of the ISPT Meeting:
 Mechanism for child-driven, familyfocused treatment
 Mechanism for individualization and
positive envisioning
 Mechanism to integrate prescriber
expertise with multi-system participation
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Interagency Service Planning
Team (ISPT)
 Desired outcomes of the ISPT Meeting:
 Achieving consensus, based on common
understanding and common goals
 Initiating and maintaining an ongoing process of
collaboration and change
 Implementing practical, workable solutions for
the child, including integrated treatment and
feasible sources of funding
Only possible with parent/guardian
participation!
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Initial ISPT
 VBH-PA will schedule meeting within seven
(7) days of receipt of evaluation
 Parent/legal guardian, CYS/JPO, child if 14
years or older, and if appropriate, county
representative, case manager, education
(home school district), VBH-PA reviewer
and other appropriate child-serving
agencies
 Evaluators are expected to participate (by
phone or in person)
 Provider is not a participant
 VBH-PA/County facilitates initial ISPT
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Ongoing & Discharge ISPT
 Provider is a participant and is responsible
to contact county to schedule the ISPT
 Provider takes the lead in discussing
progress of treatment goals, interventions
utilized, skill transfer, barriers to treatment
and discharge planning
 Discharge planning meeting within 45 days
of a projected discharge date
 Provider facilitates ongoing/discharge
ISPT’s
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Definition of Medically
Necessary
 A service, item, procedure or level or care that is
necessary for the proper treatment or management of
an illness, injury or disability is one that:
 Will, or is reasonably expected to, prevent the onset
of an illness, condition, or injury or disability.
 Will, or is reasonably expected to, reduce or
ameliorate the physical, mental or developmental
effects of an illness, condition, injury or disability.
 Will assist the recipient to achieve or maintain
maximum functional capacity in performing daily
activities, taking into account both the functional
capacity of the recipient and those functional
capacities that are appropriate of recipients of the
same age.
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Medical Necessity Criteria
 Licensed as an utilization review
entity
 Mandated to use Appendix T, Program
Standards and Requirements
 SI – Severity of Illness
 IS – Intensity of Service
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Peer Review
 Care Managers and CAFS Coordinators can only
authorize care
 Medical Necessity is questioned
 Peer Advisors render decisions
 Certified
 Non-certified (denial)
 Peer Advisors are board certified psychiatrists,
licensed psychologists and addictionologists
supervised by the MCO Medical Director
 Peer Advisors are also available 24/7 and a
monthly on-call schedule is maintained
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What is a denial of service?
 A VBH-PA Peer Advisor’s decision to deny a
service, to decrease a service or to
approve a service different than the
service requested because the care
requested is not medically necessary or
another level of care is more appropriate.
 The member will be sent a denial letter on
the same date the denial is given for all
acute levels of care. For non-acute levels
of care, the denial letter is sent to the
member within two business days of the
denial decision.
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What is a Grievance?
A grievance is when you are unhappy
about a decision made about your
treatment:
• You may be denied a service.
• A decision was made to decrease the
amount of service.
• You want a different service than
what has been approved.
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How do I file a Grievance?
• You will receive a letter when VBH-PA denies a
service, decreases your service, or approves
something different than the service requested.
• There can be several steps to the Grievance
Process including:
• First Level Grievance
• Second Level Grievance
• External Grievance
• Fair Hearing
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First and Second Level
Grievances
• You may send your Grievance in letter
form or you may call VBH-PA.
• Use the toll-free number on your card or
have someone call for you.
• Your provider may also file a Grievance
for you, if you give them written
permission to do so.
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How Soon Must I File?
• You have 45 days to file a Grievance
after you receive written notice of the
change in your service.
• You may continue services through the
Grievance process if you file within 10
days of your service being denied.
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If you are not satisfied
File a complaint if you are unhappy
with the HealthChoices program.
• you do not like the care your provider is
giving you
• you are unhappy with the services you
are receiving
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Examples of Complaints
• I waited too long in the office.
• The staff is rude.
• The doctor will not let me take part in
deciding my care.
• I was late because I could not get a
ride or the bus was late and my
appointment was cancelled.
• I received a bill from my provider.
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How to File a Complaint
• Call the toll-free number on your card or
have someone call for you.
• All calls are free.
• Write a letter to:
VBH-PA
520 Pleasant Valley Road
Trafford, PA 15085
Attention: Quality Department
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Need Help Filing...
• A VBH-PA Member Services
Representative can help you file a
complaint.
• Your complaint will be investigated
within 30 days.
• You will be sent a letter from
VBH-PA informing you of the
resolution.
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What if I still don’t like the
resolution?
• You may file a Second Level Complaint
by calling or writing VBH-PA.
• You have the right to meet with the
Second Level Complaint Committee to
resolve your complaint.
• This committee will meet within 30
days of your request and you will be
notified of the results by a letter from
VBH-PA.
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Still not happy?
• You have 15 days to file an External
Complaint Review.
• This complaint is handled by either the
Pennsylvania Department of Health
(DOH) or the Pennsylvania Department
of Insurance (DOI).
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Questions???
•
VBH-PA is committed to providing
quality behavioral health services
to all our Members.
•
VBH-PA wants its’ Members to
strive for recovery and enjoy a
good quality of life.
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