Transcript HealthChoices Behavioral Health Contract Changes

HealthChoices Behavioral Health
Contract Changes
Children in Substitute
Care (CISC) Placed
Out of Zone (OOZ)
1
9/15/2009
Department of Public Welfare
of and
Public
Welfare
OfficeDepartment
of Mental Health
Substance
Abuse
October
23, 2006
Office
of Mental Health and Substance
HealthChoices Behavioral Health
Statewide Expansion
Draft 3/9/06
Abuse Services
HEALTHCHOICES BEHAVIORAL HEALTH ZONES
Erie
VBH
45,650
Crawford
VBH
13,711
Mercer
VBH
18,388
Venango
VBH
8,911
Warren
4,954
CCBHO
Forest
635
CCBHO
McKean
6,895
CCBHO
Elk
3,989
CCBHO
Potter
2,715
CCBHO
Cameron
857
CCBHO
Tioga
5,209
CCBHO
Lycoming
CBHNP
15,136
Bradford
9,325
CCBHO
Sullivan
709
CCBHO
Susquehanna
CCBHO
5,576
Wyoming
CCBHO
3,637
Wayne
6,080
CCBHO
Lackawanna
CCBHO
27,644
Pike
CCBHO
4,888
Luzerne
Clinton
Clarion
CCBHO
CBHNP
5,443 Jefferson
43,462
5,315
Columbia
CCBHO
Monroe
7,146
7,101
Lawrence
CCBHO
CCBHO
Union
Montour
Clearfield
VBH
18,537
Centre
Butler
3,396
1,924
Carbon
13,392
14,377
9,319
VBH
CCBHO
CCBHO
CCBHO
CCBHO
Armstrong
CCBHO
14,594
6,574
Northumberland
VBH
Snyder
11,160
Northampton
Beaver
9,887
3,531
CCBHO
Schuylkill
MBH
Indiana
CCBHO
17,407
Cambria
Lehigh 26,451
VBH
23,146
CCBHO
VBH
Mifflin Juniata
MBH
9,792
19,882
6,744 2,199
46,198
Allegheny
Berks
Blair
CCBHO
Dauphin
Bucks
CCBHO
CCBHO
CBHNP
CBHNP
MBH
Perry
150,640
53,075
20,681
CBHNP
33,195 Lebanon
34,259
Westmoreland
4,054
Huntingdon
CBHNP
VBH
Montgomery
6,112
12,975
Washington
38,452
MBH
Cumberland
CCBHO
VBH
41,318
CBHNP
24,223
Lancaster
12,687
CBHNP
Chester
45,373
CCBHO
Philadelphia
Somerset
Bedford
CBH
Fayette
CBHNP
CBHNP
Franklin
23,673
York
VBH
Greene
9,156
6,275
Fulton CBHNP
Adams
Delaware 411,226
CCBHO
29,793
11,712
CCBHO
VBH
CBHNP
MBH
39,242
6,962
7,555
1,709
59,416
2
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
9/15/2009
* Covered lives as of July 2007
Prior to August 1, 2009…D&A OOZ






3
Youth offended - appeared before the Judge
Judge ordered placement in a D&A
residential non-hospital program
Court ordered where youth is placed
Youth remained until order was satisfied
Juvenile Justice system paid
No coordination of care with BH-MCO
9/15/2009
After August 1, 2009…D&A OOZ




4
Youth Offends and goes before the Judge
Judge orders drug and alcohol assessment
ASAM Criteria affirms need for D&A nonhospital residential rehab
BH-MCO contacted and reviews for medical
necessity – placement options offered at
network provider or requested provider is
approved
9/15/2009
After August 1st contd. 




5
BH-MCO Care Managers conduct periodic
review of ongoing medical necessity
Youth remains in treatment until criteria is no
longer met or until court orders release
BH-MCO pays while medically necessary
C&Y can pay if no longer med necessay
After-care is coordinated through the BHMCO
9/15/2009
What is Potentially Different ?





6
Drug and alcohol assessment completed
prior to placement
BH-MCO is contacted prior to placement
Youth is placed in a D&A treatment bed
BH-MCO pays for the treatment episode –
can include room & board
BH-MCO arranges for after-care upon return
home
9/15/2009
Key Considerations






7
Inserting the BH-MCO in the process
Interface with New BH-MCOs
Use of the ASAM Criteria
Need to have youth in licensed D&A
treatment beds
Providers may need to enroll in PROMISE
Rates are set by the BH-MCOs
9/15/2009
Prior to August 1st – CISC OOZ





8
Dependent child is placed out of their
HealthChoices Zone
Child remains or reverts to MA – FFS
Accesses BH services directly
TSS and RTF prior authorized through
OMHSAS Medical Assistance Prior Auth Unit
BH-MCO not responsible for coordination of
care
9/15/2009
After August 1st – CISC OOZ




9
Dependent child is placed outside of zone
Child remains in, or is enrolled in, the BHMCO of original residence
BH-MCO to be contacted for review of
medical necessity (Appendix T)/auth of
service
Provider enrolls in BH-MCO’s network or is
authorized as out-of-network provider
9/15/2009
What is Potentially different?





10
Service authorization must be requested of BHMCO of child’s residence
BH-MCOs may have different policies, procedures
and rates
All apply Medical Necessity Criteria found in
Appendix T
BH-MCOs pay for services authorized
Care is coordinated by BH-MCO upon child’s return
9/15/2009
Key Considerations
-



11
Additional services may be available in HC
Physical Health coverage is not impacted
HealthChoices rates are often higher than
FFS
Providers must be enrolled in MA and
credentialed to be in BH-MCO networks
9/15/2009
Which issues do not change?

Children in Detention Centers more than 35
days
–
–
12
Children in detention centers more than 35 days
will continue as FFS. Authorizations requested
while the child is in detention will be conducted by
OMHSAS UR.
If the child is placed before an authorization is
requested, the BHMCO will need to review for
medical necessity before payment can be made.
9/15/2009