Embed Size (px)
Citation preview
1
Explaining County Mental Health and Substance Use Funding
June 13, 2019
Welcome
Jaime WelcherEducation Program ManagerCalifornia Hospital Association
1
2
2
Continuing Education
All registered participants will receive a recorded version of the webinar within one week. We are offering Continuing Education for this program for health care executives.
Full attendance and completion of the online evaluation and attestation of attendance are required to receive CE’s for today’s webinar. CEs are complimentary and available for registrants only.
3
Faculty
Sheree Lowe is the Vice President of Behavioral Health for CHA. In this capacity, she staffs CHA’s Center for Behavioral Health Advisory Board. She is also responsible for hospital-based outpatient clinic (HBOC) issues and staffs CHA’s HBOC workgroup.
4
3
4
3
Faculty
Kirsten Barlow, MSWMs. Barlow is a Senior Consultant on Behavior Health Policy. She is a Strategic Partner to Harbage Consulting bringing nearly twenty years of reputable experience and leadership in the behavioral health and social services sectors. Prior to that, she served as the Executive Director of the County Behavioral Health Directors Association (CBHDA) of California, and was the Executive Officer of the Council on Mentally Ill Offenders. Kirsten has also worked at the California Department of Mental Health, Los Angeles County Department of Mental Health, and for the State Legislature’s Assembly Human Services Committee.
5
A Primer: California’s County Behavioral Health Financing
June 2019
Kirsten Barlow, MSW, Senior Consultant, Behavioral Health [email protected], (916) 217-3440
5
6
4
77
Overview
Funding Sources 1991 Realignment 2011 Realignment Mental Health Services Act Other Funds
Service System Roles of federal, state, county government Medi-Cal Specialty Mental Health Services Accessing Psychiatric Inpatient Hospital Services
Appendix Additional information on Medicaid waivers and state plan amendments Definitions of covered Medi-Cal Specialty Mental Health Services
8
Common Acronyms
ACA: Affordable Care Act CMS: Centers for Medicare and Medicaid
Services CPE: Certified Public Expenditure DHCS: Department of Health Care Services DMC: Drug Medi-Cal DMC-ODS: Drug Medi-Cal Organized Delivery
System Pilot Program EPSDT: Early and Periodic, Screening,
Diagnostic, and Treatment Benefit FFP: Federal Financial Participation
FFS: Fee-For-Service FMAP: Federal Medical Assistance Percentage MCP: Medi-Cal Managed Care Plan MHP: Mental Health Plan MHSA: Mental Health Services Act MHSUDS: Mental Health and Substance Use
Disorder Services SMHS: Specialty Mental Health Services SPA: [Medicaid] State Plan Amendment SUD: Substance Use Disorder
7
8
5
9
Key Behavioral Health Programs
Mental Health
Medi-Cal Managed Care Plan benefits
Medi-Cal Mental Health Plan specialty benefits
Mental Health Services Act LPS Act Responsibilities
Substance Use Disorders
Drug Medi-Cal benefits Drug Medi-Cal Organized
Delivery System pilot Substance Abuse Prevention
Block Grant
County Revenue Sources
10
9
10
6
1111
Funding Snapshot: Mental Health Services
Mental Health Services
2011 Realignment
Federal Financial
Participation 1991
Realignment
Mental Health Services Act
County General Funds
SAMHSA Grants
11
State General Funds
1212
Substance Use Disorder Treatment
State General Funds
2011 Realignment
SAPT Block Grants
Federal Financial
Participation
County General Funds
Funding Snapshot: Substance Use Disorder Treatment
11
12
7
County Mental Health Funding in California
1414
$8 Billion Supports California’s County Mental Health Services (FY 2019-20 Estimate)
Federal Medicaid Matching Funds
(FFP)$2,699,916,340
33%
Mental Health Services Act (MHSA)
$2,258,600,000 27%
1991 Realignment Mental Health$1,291,400,000
16%
2011 Realignment$1,663,200,000
20%
Other Funds$350,000,000
4%
14
13
14
8
15
1991 Realignment
15
1616
1991 Mental Health Realignment
1991 Realignment transferred program responsibility from the state to counties Made county mental health agencies responsible for serving children and
adolescents who have a serious emotional disturbance, and adults and older adults who have a serious mental illness, based on availability of resources, including: All community-based mental health services, including LPS Act responsibilities State hospital services for civil commitments “Institutions for Mental Disease” which provided long-term nursing facility care
These funds may be used as match to federal Medi-Cal claims when services are provided to Medi-Cal beneficiaries
15
16
9
17
1991 Mental Health Realignment and the IMD Exclusion
Federal regulations define an IMD as a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services
A facility’s license type is not a defining characteristic of an IMD; several types of facilities may meet the definition of an IMD, including but not limited to, acute psychiatric hospitals, mental health rehabilitation centers, psychiatric health facilities, and skilled nursing facilities with special treatment programs
FFP is not available in expenditures for services provided to … Individuals under age 65 who are patients in an institution for mental diseases unless they are under age 22 and are receiving inpatient psychiatric services under Sec. 440.160 of this subchapter
MHPs are responsible for preventing the submission for claims to the State for services provided to individuals subject to the IMD exclusion
1818
1991 Mental Health Realignment
Realignment revenues are distributed to counties on a monthly basis as funds are collected until each county receives funds equal to previous year’s total Separate distributions for: Mental Health (fixed, guaranteed amount) Mental Health Sales Tax Base (1/2 cent) Mental Health Vehicle License Fee (VLF) Base Mental Health VLF Collections
CalWORKs Maintenance of Effort funded prior to the funding of Mental Health Sales Tax Base and Mental Health VLF Base
Revenues above that amount are placed into growth accounts Sales Tax VLF
18
17
18
10
1919
Temporary Redirection of 1991 Mental Health Growth: In Home Supportive Services (IHSS)
In 2017, Governor Brown and counties negotiated a new county MOE and annual inflation factor for IHSS program costs Included a temporary redirection of all 1991 Realignment growth funds from
county indigent health and mental health services to fund a portion of county IHSS costs
Governor Newsom’s January 2019 Budget proposes to increase State General Fund spending on IHSS, discontinuing the redirection of counties’ mental health 1991 Realignment growth funds (estimated FY 2018-19 growth is $84 million)
19
20
2011 Realignment
20
19
20
11
2121
Public Safety 2011 Realignment
2011 Realignment shifted funding and service responsibility from the state to the counties for: Law enforcement, social services, behavioral health Driven by the state budget crisis, not counties
Dedicated specific revenue to fund realigned services: 1.0625% of Sales Tax Motor Vehicle License Fee Transfer to fund law enforcement program Realigned services previously funded with State General Fund monies On a one-time basis in the first year of 2011 Realignment, MHSA funds were used
to fund all realigned mental health services, as well as the final year of counties’ AB 3632 special education mental health obligations (over $800 million)
21
2222
Proposition 30 Constitutional Protections
State must provide funds for new laws or new regulations, executive orders, administrative directives that increase costs of local services mandated by 2011 Realignment legislation Unless the state provides funding, state cannot submit federal plans/waivers/SPAs
that increase local costs State provides 50% of needed funds for changes to federal statutes/regulations or
federal judicial or administrative proceedings
22
21
22
12
2323
2011 Realignment Behavioral Health Subaccount
Medi-Cal Specialty Mental Health Managed Care Including Early and Periodic Screening, Diagnosis and Treatment (EPSDT) mental
health benefits for children and youth.Drug Medi-Cal Including Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
substance use disorder treatment benefits for children and youthDrug CourtsPerinatal Drug ServicesNon-Drug Medi-Cal Services
23
2424
Realignment 2011 and Medi-Cal Specialty Mental Health Services
Counties must fund Medi-Cal Specialty Mental Health Services, including Early and Periodic Screening, Diagnosis and Treatment (EPSDT), with moneys received from all of the following sources: The 2011 Behavioral Health Subaccount and the Behavioral Health Growth Special
Account The 1991 Realignment Mental Health Subaccount MHSA funds, to the extent permissible under the Act
24
23
24
13
2525
Realignment 2011 and Medi-Cal Specialty Mental Health Services (cont.)
If a county is failing or at-risk of failing to perform the functions of a Behavioral Health Subaccount program to the extent federal funds are at risk, DHCS will: Notify the State Controller, Department of Finance, and the county; Determine the amount needed from the subaccount to perform the function; and Work with the controller to deposit the county’s allocation attributable to the
program into the “County Intervention Support Services Subaccount” (for access by DHCS for the program) DHCS determines when this may cease
25
26
Mental Health Services Act
26
25
26
14
2727
Mental Health Services Act (MHSA) Revenues
The MHSA created a 1% tax on income in excess of $1 million to expand mental health services
Two primary sources of deposits into State MHS Fund: 1.76% of all monthly personal income tax (PIT) payments (Cash Transfers); and Annual adjustment based on actual tax returns: Settlement between monthly PIT
payments and actual tax returns
27
28
Total MHSA Revenue (2009-2020)
Dollars In Millions$3,000.0
$2,398 $2,378$2,500.0
$1,395$1,140
$849
$1,685$1,282
$1,831 $1,871 $1,798
$2,095
$500.0
$0.0
$1,000.0
$1,500.0
$2,000.0
($500.0)09/10Actual
10/11Actual
11/12Actual
12/13Actual
13/14Actual
14/15Actual
15/16Actual
16/17Actual
17/18Actual
18/19Estimated
19/20Projected
Cash Transfers Annual Adjustment Interest Income TOTAL
Source: Mental Health Services Oversight and Accountability Commission, Meeting Packet - January 2019, January 16, 2019
27
28
15
2929
Mental Health Services Act Revenues (cont.)
Cash Transfers are largest in months with quarterly tax payments and year end tax payments: January, April, June and September
Annual Adjustments are incredibly volatile: Two-year lag Known by March 15th
Deposited on July 1st
State’s estimate is typically 50% or more off from actual
29
30
Key Responsibilities for the Mental Health Services Act (MHSA)
Federal
State
County
Centers for Medicare & Medicaid Services (CMS) Provides federal financial participation (FFP) to match eligible local
MHSA expenditures (Medicaid matching funds)
California Department of Health Care Services (DHCS) Oversight / monitoring of county MHSA expenditures Reports to the Legislature Processes county claims for FFP Promulgates regulations, Info Notices, distribution methodologyMental Health Services Oversight & Accountability Commission Oversight / monitoring of county MHSA expenditures Promulgates regulations Approves MHSA Innovation plans
County Mental Health Plan (MHP) / County Drug Medi-Cal Program Administers / provides payment for mental health / substance
use disorder programs for Medi-Cal enrollees Contracts with providers to deliver services
30
29
30
16
3131
MHSA County Funding
Funds distributed on a monthly basis Unexpended and unreserved funds on deposit in the State MHS Fund at the end of
the month are distributed by the 15th of the next month Formula described each year in DHCS Information Notices
County-by-county distributions based on a formula Factors include prevalence of mental illness, poverty population, Medi-Cal
population, self-sufficiency levels, available resourcesCounties receive one monthly warrant (check) from the state Counties are responsible for ensuring they use revenues as follows: 20% for Prevention and Early Intervention programs 5% for Innovative Programs The balance for Community Services and Supports
31
3232
MHSA County Expenditures
Counties are required to prepare a Three-Year Program and Expenditure Plan and an Annual Update Estimated funding and expenditures by component
Counties gain Board of Supervisors’ approval of the Three-Year Program and Expenditure Plan and Annual Update through a required stakeholder process Innovation plans must also be approved by the Mental Health Services Oversight &
Accountability Commission (MHSOAC) All MHSA expenditures are required to be in accordance with an approved Plan MHSA funds cannot be used to supplant existing resources or other program obligations Counties must submit an MHSA Annual Revenue and Expenditure Report to DHCS
32
31
32
17
3333
MHSA Prudent Reserves & Reversion
State statute requires counties to establish and maintain a prudent reserve to ensure service continuity in years that revenues are below average. Prudent reserve balances must not to exceed 33% of the average CSS revenue
received in the preceding 5 years
State statute requires funds to be spent within a certain time period, or returned to the state to distribute to other counties Counties must spend funds within 3 years Small counties now have 5 years Innovation “clock” starts once the MHSOAC approves the county’s plan
33
34
Other Revenue Sources
34
33
34
18
3535
Miscellaneous Funding
Counties contribute additional county funds (overmatch) based on the availability of local revenues and local priorities Varies significantly by county – counties with public hospitals tend to have higher
county contributions
SAMHSA funds the Mental Health Block grant: $57.4 million
Other third party revenues: Insurance Medicare
35
36
Medi-Cal Specialty Mental Health Services
36
35
36
19
37
Key Responsibilities for Medi-Cal
Federal
State
County
Centers for Medicare & Medicaid Services (CMS) Sets standards for Medicaid programs and provides regulatory
oversight Provides federal financial participation (FFP) to match eligible
state/local expenditures (Medicaid matching funds)
California Department of Health Care Services (DHCS) Oversight/monitoring of Medi-Cal program Processes county claims for FFP CA’s Medicaid state plan describes the scope, amount, and
duration of covered benefits Waivers are vehicles for states to test new/alternative ways to
deliver and pay for health care services in Medicaid (e.g., a managed care delivery system)
County Mental Health Plan (MHP)/County Drug Medi-Cal Program Administers/provides payment for mental health/substance use
disorder programs for Medi-Cal enrollees Contracts with providers to deliver services
37
Key Programmatic Authorities
Medi-Cal State Plan & State Plan Amendments
(Targeted Case Management, Rehabilitative
Mental Health Services)
DHCS Information Notices
California Code of Regulations
(Title 9)
State Statute (Mental Health Services Act, Bronzan-McCorquodale Act, Lanterman-Petris-Short Act)
State-County Contracts(MHP Contract,
Performance Contract)
Medicaid Waivers (1915(b) Medi-Cal Specialty
Mental Health Services Consolidation Waiver)
Federal Medicaid Managed Care Regulations
38
37
38
20
39
Medi-Cal Mental Health Services
County Specialty Mental Health Plan
Enrollee and Family
Providers
Medi-Cal Managed
Care Plans
DHCS Fee-for-Service
County Mental Health Plans
The two primary systems of care for Medi-Cal beneficiaries with mental health conditions today are:1) County MHPs: Responsible for authorization and
payment of a full continuum of specialty mental health services, including inpatient/post-stabilization services, rehabilitative services and targeted care management for beneficiaries meeting statewide medical necessity criteria.
2) MCPs/DHCS Fee-For-Service: Responsible for outpatient mental health services, including psychotherapy and medication management for beneficiaries with “mild-to-moderate” mental health conditions.
39
40
Medi-Cal Mental Health BenefitsMedi-Cal Managed Care Plan County Mental Health Plan
Outpatient Mental Health Services
1. Services within Primary Care Provider Scope of Practice
2. Individual and Group Mental Health Evaluation and Treatment
3. Psychological Testing4. Medication Management5. Outpatient Laboratory,
Medications, Supplies, and Supplements
6. Psychiatric Consultation
1. Psychiatric Inpatient Hospital Services2. Rehabilitative Mental Health Services
a. Mental Health Servicesb. Medication Support Servicesc. Day Treatment Intensived. Day Rehabilitatione. Crisis Interventionf. Crisis Stabilizationg. Adult Residential Treatmenth. Crisis Residential Treatment Servicesi. Psychiatric Health Facility Services
3. Targeted Case Management, including: Comprehensive Assessment and Periodic Reassessment, Development and Periodic Revision of a Client Plan, Referral and Related Activities, Monitoring and Follow-up Activities
4. EPSDT Services, including: Therapeutic Behavioral Services, Therapeutic Foster Care, Intensive Home-Based Services, and Intensive Care Coordination
40
39
40
21
Rehabilitative Mental Health Services – “Mental Health Services” Definition
Individual or group therapies and interventions Reduce mental disability Restore, improve or maintain functioning Goals: learning, development, independent living, enhanced
self-sufficiency Services include: Assessment Plan Development Therapy Rehabilitation Collateral
41
Medi-Cal Managed Care Plans’ Outpatient Mental Health Services
Boilerplate Contract Between DHCS and Each Planhttps://www.dhcs.ca.gov/provgovpart/Pages/MMCDBoilerplateContracts.aspx
42
41
42
22
Accessing Counties’ Medi-Cal Specialty Outpatient Mental Health
Medi-Cal eligible beneficiaries are automatically enrolled in the single MHP in their county. A Medi-Cal beneficiary is eligible for SMHS if he or she meets all of the following criteria: Has an included diagnosis Has a significant impairment in an important area of life functioning, or a reasonable
probability of significant deterioration in an important area of life functioning; or a reasonable probability of not progressing as individually appropriate (for beneficiaries under 21 who meet criteria for EPSDT)
The focus of the proposed treatment is to address the impairments The expectation is that the proposed treatment will significantly diminish the impairment,
prevent significant deterioration in an important area of life function The condition would not be responsive to physical health care-based treatment
43
4444
MHP Coverage Responsibilities
Referrals - Under the wavier program, referrals to the MHP for SMHS may be received through beneficiary self-referral or referral by another person or organization
Assessments - MHPs may not deny an initial assessment to determine whether a beneficiary meets the medical necessity criteria for receiving services from the MHP. MHPs may require that assessments be requested through a formal system.
Limited to SMHS - The waiver program is limited to coverage of SMHS EPSDT - MHPs are not responsible for the screening function of EPSDT. MHPs may
perform the diagnosis function through assessments of beneficiaries requesting services. MHPs are responsible for arranging for, or providing, “corrective treatment” identified by a screening and referral or by the MHP’s own assessment process
44
43
44
23
4545
MHP Contract
State-County Contract - State law (WIC) directs DHCS to “implement managed mental health care for Medi-Cal beneficiaries through contracts with MHPs.” DHCS shall contract with a county (or counties acting jointly) for the delivery of SMHS to each county’s eligible Medi-Cal population
County Unable/Unwilling to Contract - If the county is unwilling or unable to adequately provider SMHS, DHCS shall ensure that SMHS are provided to Medi-Cal beneficiaries. DHCS shall work with the Department of Finance and the Controller to sequester funds from the county that is unable or unwilling to contract
MHP Responsibility under Contract - The MHP is financially responsible for ensuring access and minimum required scope of benefits and services to Medi-Cal beneficiaries who are residents of that county, regardless of where the beneficiary resides (exception: “presumptive transfer” for foster children)
45
MHP Contract (cont.)
Services shall be provided, in accordance with the State Plan, to beneficiaries, who meet medical necessity criteria, based on the beneficiary’s need for services established by an assessment and documented in the client plan. Services shall be provided in an amount, duration, and scope as specified in the individualized Client Plan for each beneficiary
The Contractor shall ensure that all medically necessary covered Specialty Mental Health Services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished. The Contractor shall not arbitrarily deny or reduce the amount, duration, or scope of a medically necessary covered Specialty Mental Health Service solely because of diagnosis, type of illness, or condition of the beneficiary except as specifically provided in the medical necessity criteria applicable to the situation as provided in the California Code of Regulations, title 9, sections 1820.205, 1830.205, and 1830.210. (42 C.F.R. § 438.210(a)(2) and (3).)
46
45
46
24
47
Medi-Cal SMHS Reimbursement Protocols
47
48
Medi-Cal Specialty Mental Health Services (SMHS) Reimbursement
County MHPs are reimbursed a percentage of their actual expenditures (Certified Public Expenditures [CPE]) based on the Federal Medical Assistance Percentage (FMAP) Same for all Medi-Cal Specialty Mental Health services except FFS / MC inpatient
hospital servicesCounty MHPs are reimbursed an interim amount throughout the fiscal year based on approved Medi-Cal services and interim billing rates Interim rates for contract providers represent amount paid by MHP to provider Interim rates for county-operated providers should approximate actual costs
48
47
48
25
49
Medi-Cal SMHS Reimbursement (cont.)
County MHPs and DHCS reconcile the interim amounts to actual expenditures through the year-end cost report settlement process DHCS audits the cost reports to determine final Medi-Cal entitlement Medi-Cal MHP Administrative costs and Utilization Review costs are reimbursed
through quarterly claims and the cost report process
49
50
Medi-Cal SMHS Reimbursement (cont.)
MHP reimbursement was limited to no more than the Schedule of Maximum Allowances (SMAs) prior to the implementation of AB 1297 in FY 2012-13 Based on lowest of actual costs and usual / customary charges
Medi-Cal MHP Administrative costs are limited to 15% of direct service reimbursement 1915(b) Waiver limits reimbursement to an Upper Payment Limit (UPL) for each MHP Based on actual CPE incurred by MHP UPL changes up until audit (and any appeals) are completely settled
50
49
50
26
51
Accessing Psychiatric Inpatient Hospital Services
For Medi-Cal reimbursement for an admission to a hospital for psychiatric inpatient hospital services, the beneficiary must meet the following medical necessity criteria: Has an included diagnosis Cannot be safely treated at a lower level of care, except that a beneficiary who can
be safely treated with crisis residential treatment services or psychiatric health facility services for an acute psychiatric episode shall be considered to have met this criterion
Requires psychiatric inpatient hospital services, as a result of a mental disorder, due to one or more risk factors (as outlined in regulations) and admission is required for further evaluation, medication treatment, or other treatment that cannot be reasonably provided if the patient is not hospitalized
51
52
Psychiatric Inpatient (cont.)
Provided in an acute psychiatric hospital or the distinct acute psychiatric portion of a general hospital (approved by DHCS)
Reimbursement criteria for Hospital Inpatient Administrative Day Services During a hospital stay, the beneficiary has previously met medical necessity for
acute psychiatric inpatient hospital services. There is no appropriate, non-acute treatment facility within a reasonable
geographic area The hospital documents contacts with a minimum of 5 appropriate, non-acute
treatment facilities per week
52
51
52
27
53
Psychiatric Inpatient (cont.)
Inpatient Psychiatric Facilities (Non-MHP Contracted) A representative authorized by the MHP must approve a mental health IP provider’s
Treatment Authorization Request (TAR) The claim system matches the claim to the TAR and adjudicates the claim The inpatient provider bills DHCS’ Fiscal Intermediary Management Division for
Medi-Cal reimbursement This type of inpatient billing is never billed directly from an MHP through DHCS
54
Third Party Coverage
Medi-Cal is always the payer of last resort MHPs must first submit claims to other payers when the beneficiary has third party
coverage When a claim is submitted by the MHP for payment, all third party payers must have
either paid or denied the claim except as noted under Dual-Eligibility Beneficiaries
53
54
28
Appendix
Medi-Cal Specialty Mental Health Programmatic Authority
1915(b) Medi-Cal Specialty Mental Health Services (SMHS) Consolidation Waiver [link] Current term is July 1, 2015 to June 30, 2020
Medi-Cal State Plan and State Plan Amendments [link] Psychiatric Inpatient Hospital Services [link] Rehabilitative Mental Health Services (Medically Needy) [link] Rehabilitative Mental
Health Services (Categorically Needy) [link] Targeted Case Management Services [link] Reimbursement Methodologies for Medi-Cal MH Services [link]
Mental Health Plan (MHP) Contract [link to 2017-2022 boilerplate] Welfare and Institutions Code Division 9, Part 3, Chapter 8.8 and 8.9 [14680 – 14685.1; 14700 – 14726]
California Code of Regulations Title 9, Division 1, Chapter 11 [1810.100 – 1850.535]
56
55
56
29
Managed Care Waiver Program
1915(b) Medi-Cal SMHS Waiver Program: The waiver authorizes a managed care structure for the delivery of SMHS to Medi-Cal enrollees. County MHPs are considered to be “prepaid inpatient health plans” – or “PIHPs”
Mandatory Enrollment: Free choice of providers is restricted. The state automatically enrolls beneficiaries on a mandatory basis into the single MHP operating in the county of the beneficiary
County Responsibility: County MHPs provide, or arrange for, SMHS for Medi-Cal enrollees in their county that meet specified medical necessity criteria
Enrollee Rights and Protections Assurance: The state and counties must comply with federal managed care regulations related to enrollee rights and protections
57
Managed Care Waiver Program – Implications
Establishes a waiver of freedom of beneficiary choice; Establishes authority to maintain a closed provider network; Establishes authority to reimburse covered services at other than state plan rates; Establishes authority for the counties to provide the required Medicaid Certified
Public Expenditure; Establishes authority for lower of cost or charge reimbursement for covered
services; and Establishes authority for units of service to be claimed based on minutes and
staff time
58
57
58
30
Federal Social Security Act (SSA) Sections Waived
Statewideness [SSA 1902(a)(1)]: Waiver program not available in all political subdivisions of the state
Comparability of Services [1902(a)(10)(B)]: Beneficiaries must meet medical necessity criteria to access waiver services
Freedom of Choice [1902(a)(23)]: Free choice of providers is restricted. Beneficiaries must receive services through MHP in their county
Disenrollment Restrictions [1902(a)(4); various CFR sections]: Permits state to mandate enrollment into a single PIHP (MHP) and restrict disenrollment
59
Medi-Cal Specialty Mental Health Service Definitions
Mental Health Services - Individual, group, or family-based interventions that are designed to provide reduction of the individual’s mental or emotional disability, restoration , improvement and/or preservation of individual and community functioning, and continued ability to remain in the community consistent with the goals of recovery, resiliency, learning, development, independent living and enhanced self-sufficiency
Medication Support Services - Prescribing, administering, dispensing and monitoring drug interactions and contraindications or psychiatric medications or biologicals that are necessary to alleviate the suffering and symptoms of mental illness
60
59
60
31
Medi-Cal SMHS Definitions (cont.)
Day Treatment Intensive (DTI) - Structured, multi-disciplinary program including community meetings, a therapeutic milieu, therapy, skill building groups, and adjunctive therapies, which provides services to a distinct group of individuals. DTI is intended to provide an alternative to hospitalization, avoid placement in a more restrictive setting, or assist the beneficiary in living within a community setting. Services are available for at least three hours/day
Day Rehabilitation - A structured program including rehabilitation, skill building groups, process groups, and adjunctive therapies which provides services to a distinct group of individuals. Day rehab is intended to improve or restore personal independence and functioning to live in the community or prevent deterioration of personal independence consistent with the principles of learning and development. Services are available for at least three hours/day
61
Medi-Cal SMHS Definitions (cont.)
Crisis Intervention - An unplanned, expedited service, to or on behalf of a beneficiary, to address a condition that requires more timely response than a regularly scheduled visit. Crisis intervention is an emergency response service enabling a beneficiary to cope with a crisis, while assisting the beneficiary in regaining their status as a functioning community member. The goal of crisis intervention is to stabilize an immediate crisis within a community or clinical treatment setting
Crisis Stabilization - An unplanned, expedited service lasting less than 24 hours, to or on behalf of a beneficiary to address an urgent condition requiring immediate attention that cannot be adequately or safely addressed in a community setting. The goal of crisis stabilization is to avoid the need for inpatient services which, if the condition and symptoms are not treated, present an imminent threat to the beneficiary or others, or substantially increase the risk of the beneficiary becoming gravely disabled
62
61
62
32
Medi-Cal SMHS Definitions(cont.)
Adult Residential Treatment Services - Recovery-focused rehabilitative services, provided in a non-institutional, residential setting, for beneficiaries who would be at risk of hospitalization or other institutional placement if they were not in the residential treatment program. The service includes a range of activities and services that support beneficiaries in their efforts to restore, improve, and / or preserve interpersonal and independent living skills and to access community support systems that support recovery and enhance resiliency
Crisis Residential Treatment Services - Therapeutic or rehabilitative services provided in a non-institutional residential setting which provides a structured program (short-term) as an alternative to hospitalization for beneficiaries experiencing an acute psychiatric episode or crisis who do not have medical complications requiring nursing care
63
Medi-Cal SMHS Definitions (cont.)
Psychiatric Health Facility Services - Therapeutic and / or rehabilitative services including one of more of the following: psychiatric, psychological, and counseling services, psychiatric nursing services, social services, and rehabilitation services provided in a psychiatric health facility licensed by the Department of Social Services. Psychiatric health facilities are licensed to provide acute inpatient psychiatric treatment to individuals with major mental disorders
64
63
64
33
65
Medi-Cal Specialty Mental Health Qualified Providers
Physicians Psychologists (including
waivered / registered clinicians) Licensed Clinical Social Workers (including
waivered / registered clinicians) Licensed Professional Clinical Counselors
(including waivered / registered clinicians) Marriage and Family Therapists (including
waivered / registered clinicians)
Registered Nurses Certified Nurse Specialists Nurse Practitioners Licensed Vocational Nurses Psychiatric Technicians Mental Health Rehabilitation Specialists Physician Assistants Pharmacists Occupational Therapists Other Qualified Providers (HS diploma or
equivalent)
66
Medi-Cal Specialty Mental Health Included Diagnoses
A. Pervasive Developmental Disorders, except Autistic Disorders
B. Disruptive Behavior and Attention Deficit Disorders
C. Feeding and Eating Disorders of Infancy and Early Childhood
D. Elimination DisordersE. Other Disorders of Infancy, Childhood, or
AdolescenceF. Schizophrenia and other Psychotic Disorders,
except Psychotic Disorders due to a General Medical Condition
G. Mood Disorders, except Mood Disorders due to a General Medical Condition
H. Anxiety Disorders, except Anxiety Disorders due to a General Medical Condition
I. Somatoform DisordersJ. Factitious DisordersK. Dissociative DisordersL. ParaphiliasM. Gender Identity DisorderN. Eating DisordersO. Impulse Control Disorders Not Elsewhere
ClassifiedP. Adjustment DisordersQ. Personality Disorders, excluding Antisocial
Personality DisorderR. Medication-Induced Movement Disorders
related to other included diagnoses
65
66
34
Speaker Contact Information
Sheree LoweVice President, Behavioral HealthCalifornia Hospital [email protected](916) 443-7401
Kirsten Barlow, MSW Senior Consultant, Behavioral Health [email protected](916) 217-3440
Questions?
Online questions:Type your question in the Q & A box, press enter
Phone questions:To ask a question, press *1
67
68
35
Upcoming Programs
Strategies for Challenging Health Plan Policies, Guidelines, and Practices That Impact Coverage and Reimbursement WebinarJune 19, 201910:00 a.m. – 12:00p.m. Pacific TimePolicy changes oftentimes have material effects on the amounts hospitals actually receive under their contracts. Providers seldom have any input into these revisions, and they are frequently imposed on providers with little or no notice. This webinar will help you understand your rights under your contract and the role you need to play when contesting these policies.
Upcoming Programs
Behavioral Health Care SymposiumDecember 9-10, Riverside
Discharge Planning for Patients Who are Homeless SummitDecember 11, Riverside (Livestreaming Available)
69
70
36
Evaluation
Thank you for participating in today’s webinar. An online evaluation will be sent to you shortly.
For education questions, contact Jaime Welcher at (916) 552-7527 or [email protected].
71
