Transcript Behavioral Health Health Choices Update

OMHSAS
HealthChoices Behavioral
Health Program
PCCYFS Children’s Services
Policy Day
October 19, 2010
OMHSAS Vision Statement
Every person with serious mental illness and/or addictive
disease, and every child and adolescent who abuses
substances and/or has a serious emotional disturbance will
have the opportunity for growth, recovery and inclusion
in their community, have access to services and supports
of their choice, and enjoy a quality of life that includes
family and friends.
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HealthChoices Oversight
Secretary
OMHSAS
Deputy Secretary
OMAP
HealthChoices
Steering Committee
Joint
Management
Children’s
Bureau
Operations
Executive
Committee
Policy
Quality Improvement
&
Medical Director
Fiscal
MIS
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HC-BH Program Overview

Statewide Mandatory MA Managed Care
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Begin in 1996- implemented statewide in 2007
1915(b) CMS Waiver of Social Security Act
Available in 67 Pennsylvania Counties
2.1 million Medical Assistance eligible members
Annual cost $2.8 billion 2010
Goals:
 Improve Access to Care
 Improve Quality of Care
 Stabilize MA Spending
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HC-BH Program Structure

BH HealthChoices Separate Contract
 County Right of First Opportunity to bid on contract
 34 total BH contracts – 32 with County Government
 DPW holds direct contract with BH-MCO for Greene County & 23
County North Central area
 OMHSAS Regional Field Office Contract Monitoring Team

BH –PH Coordination Meetings
 HealthChoices PH Contracts
 ACCESSPlus PH Contracts
 PH Voluntary Contracts
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Department of Public Welfare
of and
Public
Welfare
OfficeDepartment
of Mental Health
Substance
Abuse
July 22,
2010 of Mental Health and Substance
Office
HealthChoices Behavioral Health
Statewide Expansion
Draft 3/9/06
Abuse Services
HEALTHCHOICES BEHAVIORAL HEALTH ZONES
Erie
VBH
52,063
Warren
5,322
CCBHO
Crawford
VBH
15,308
Mercer
VBH
19,875
Venango
VBH
9,186
Forest
656
CCBHO
McKean
7,408
CCBHO
Elk
4,402
CCBHO
Potter
2,793
CCBHO
Cameron
985
CCBHO
Bradford
9,457
CCBHO
Tioga
5,475
CCBHO
Lycoming
CBHNP
16,888
Sullivan
710
CCBHO
Susquehanna
CCBHO
5,688
Wyoming
CCBHO
4,021
Wayne
6,620
CCBHO
Lackawanna
CCBHO
Pike
32,114
CCBHO
5,986
Luzerne
Clinton
Clarion
CCBHO
CBHNP
5,780
50,587
Jefferson
5,827
CCBHO
Columbia
Monroe
7,781
7,842
Lawrence
CCBHO
CCBHO
Union
Montour
Clearfield
VBH
22,615
Centre
3,865
2,133
Carbon
14,265
15,305 Butler
10,002
VBH
CCBHO
CCBHO
CCBHO
CCBHO
Armstrong
CCBHO
16,576
7,681
Northumberland
VBH
Snyder
12,963
Northampton
Beaver
10,674
4,187
Schuylkill
MBH
CCBHO
Indiana
CCBHO
20,654
Cambria
Lehigh 31,636
VBH
24,735
CCBHO
VBH
Mifflin Juniata
MBH
10,885
21,515
7,608 2,679
50,561
Allegheny
Berks
Blair
CCBHO
Dauphin
Bucks
CCBHO
CCBHO
CBHNP
CBHNP
MBH
Perry
166,394
61,473
21,983
CBHNP
37,631 Lebanon
44,761
Westmoreland
4,523
Huntingdon
CBHNP
VBH
Montgomery
6,519
15,647
Washington
43,545
MBH
Cumberland
CCBHO
VBH
58,478
CBHNP
25,302
Lancaster
16,449
CBHNP
Chester
56,734
CCBHO
Philadelphia
Somerset
Bedford
30,226
CBH
Fayette
CBHNP
CBHNP
Franklin
York
VBH
Greene
9,636
6,912
Fulton CBHNP
Adams
Delaware 447,415
CCBHO
30,697
15,168
CCBHO
VBH
CBHNP
MBH
46,905
8,355
7,493
2,130
68,349
SOUTHWEST
Implemented Jan. 1999
LEHIGH/CAPITAL
Implemented Oct. 2001
SOUTHEAST
Implemented Feb. 1997
NORTHEAST
Implemented July 1, 2006
NORTH/CENTRAL STATE OPTION
BH Implementation Jan. 1, 2007
NORTH/CENTRAL COUNTY OPTION
BH Implementation July 1, 2007
* Covered lives as of July 2010
SOUTHWEST
LEHIGH/CAPITAL
SOUTHEAST
Implemented
Jan. 1999
Implemented Oct. 2001
Implemented Feb. 1997
NORTHEAST
NORTH/CENTRAL
RIGHT OF FIRST OPPORTUNITY
BH Implementation
July 1, 2006
BH Implementation
BH Implementation
January 1, 2007
July 1, 2007
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Contractual Requirements
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Programmatic:

Access to Services
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Ongoing Review of Required Services
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Complaints and Grievance Processes
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Contractual Requirements
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Development of Services
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Who decides to add a services?
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When is the decision made?
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Who pays for the new services?
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What about room and board?
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Provider Network & Credentialing
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Contractual Requirements

Financial
 Claims Payment
 Timely filing of Claims
 Clean Claims
 Primary Contractor Shall adjudicate:
 90% Clean Claims within 30 days
 100% Clean Claims within 45 days
 100% of all claims within 90 days
 Timeliness for Reimbursement
 Third Party Liability
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Eligibility Requirements
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Are there still different zones?
Who is responsible for out-of-state placements?
Who is responsible for checking eligibility?
What happens when there is dropped eligibility?
HIP/FFS
Eligibility in Juvenile Detention Centers
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Timelines Standards For Authorization
and Payment of Services
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State Standards/Bulletins
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OMHSAS- 10-04-Psychological/Psychiatric/Clinical
Re-Evaluations and Re-Authorizations for BHRS

OMAP- 01-93-04- Payment for MH services Provided
in a RTF for Eligible Individuals Under 21 Years of
Age
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OMAP- 1165-95-01- JCAHO Accredited Services
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Medical Necessity Criteria
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Evaluation and documentation-Physician (Psychiatrist)
or Licensed Psychologist
Severity of the illness present meets criteria for specific
level of care/service.
Potential for person to benefit from this level of care.
Most appropriate and least restrictive to meet MH needs.
Continued Care Criteria- person continues to meet
criteria and benefit from service.
Discharge/Referral Criteria
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Access to Service

The provider network must provide face-to-face treatment
intervention within:
 One hour for emergencies
 Twenty-four hours for Urgent situations
 Seven days for routine appointments and for specialty
referrals.
 Upon initial face-to-face intervention, the
implementation of the treatment services must adhere
to the prescribed treatment plan, including the start date
and frequency of treatment services.
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Evidence Based Practices
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MST, FFT, MTFC, PCIT
Researched Based
Over 75% Counties at least one EBP
What do we need to know?
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Must meet MA Requirements
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Must maintain fidelity/certification to model
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Questions
&
Discussion
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Contact Information
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Julie Barley- Acting Director for Eastern [email protected]
Valerie Vicari- Director for Western [email protected]
Stan Mrozowski- Director, Children’s [email protected]
Scott Talley- Chief of Operations & Service Delivery,
Children’s Bureau- [email protected]
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