SB 58 Behavioral Health Carve In. Page 1

Transcription

1 SB 58 Behavioral Health Carve In Page 1

2 Behavioral Health Integration Advisory Committee Established by the Senate Bill 58 of the 83rd Legislative Session Tasked with providing formal recommendations to HHSC by September 2014 The inclusion of mental health targeted case management and mental health rehabilitative services in Medicaid managed care The integration of behavioral and physical health services within managed care The selection of two health home pilots programs in two health service areas of the State Expires September 1, 2017 Page 2

3 Effective September 1, 2014 Behavioral Health Carve In Targeted case management and mental health rehabilitative services will be included in the managed care benefit package The NorthSTAR service area will continue to receive targeted case management and mental health rehabilitative services through the NorthSTAR delivery model NorthSTAR service area: Dallas, Ellis, Collin, Hunt, Navarro, Rockwall and Kaufman counties Page 3

4 Eligible Populations Mental health rehabilitative services and mental health targeted case management are available to Medicaid recipients who are assessed and determined to have: A severe and persistent mental illness such as schizophrenia, major depression, bipolar disorder or a other severely disabling mental disorder Children and adolescents ages 3 through 17 years with a diagnosis of a mental illness or who exhibit a serious emotional disturbance Page 4

5 Future Managed Care Services Targeted Case Management Must be face to face Include regular, but at least annual, monitoring of service effectiveness Proactive crisis planning and management for individuals Targeted case management is a Medicaid billable service provided separate from MCO service coordination MCO must ensure that STAR Service Management units and STAR+PLUS Service Coordinators coordinate with providers of TCM to ensure integration of behavioral and physical health needs of Members. MCO must ensure that if a Member loses Medicaid eligibility, STAR Service Management units and STAR+PLUS Service Coordinators refer the Member to Local Mental Health Authorities that can provide indigent mental health care. Mental Health Rehabilitative Services include Crisis Intervention Services Medication Training and Support Services Psychosocial Rehabilitative Services Skills Training and Development Services Day Programs for Acute Needs Page 5

6 Mental Health Rehab Service Codes Modifier ET HA HQ TD Day Program Service Adult Day Program for Acute Needs Description Emergency treatment Child/adolescent program Group setting RN Procedure Modifier 1 Modifier 2 FFS Rate Unit Code G0177 $ min Page 6

7 Mental Health Rehab Service Codes Medication Training and Support Service Procedure Code Modifier 1 Modifier 2 FFS Rate Unit Medication Training and Support Group services for the adult Individual services for the child and adolescent (with or without other individual) Group services for the child and adolescent (with or without other group) H0034 $ min H0034 HQ $ min H0034 HA $ min H0034 HA HQ $ min Page 7

8 Mental Health Rehab Service Codes Crisis Intervention Service Procedure Code Modifier 1 Modifier 2 FFS Rate Unit Adult services H2011 $ min Child and Adolescent services H2011 HA $ min Page 8

9 Mental Health Rehab Service Codes Skills Training and Development Service Individual services for adult Group services for adult Individual services for the child and adolescent (with or without other individual) Group services for the child and adolescent Procedure Code Modifier 1 Modifier 2 FFS Rate Unit H2014 $ min H2014 HQ $ min H2014 HA $ min H2014 HA HQ $ min Page 9

10 Mental Health Rehab Service Codes Psychosocial Rehabilitative Services Service Procedure Code Modifier 1 Modifier 2 FFS Rate Unit Individual H2017 $ min services Individual H2017 TD $ min services rendered by an RN Group services H2017 HQ $ min Group services H2017 HQ TD $ min rendered by an RN Individual crisis services H2017 ET $ min Page 10

11 Targeted Case Management Codes Service Routine mental health targeted case management (adult) Routine case management (child and adolescent) Intensive case management (child and adolescent) Procedure Code Modifier Limitations FFS Rate Unit T1017 TF 32 units (8 $ min hours) per calendar day for clients who are 18 years of age and older T1017 TF, HA, 32 units (8 $ min hours) per calendar day for clients who are 17 years of age and younger T1017 TG, HA, 32 units (8 $ min hours) per calendar day for clients who are 17 years of age and younger Page 11

12 Mental Health Rehab Service Codes The MCO is not responsible for providing Criminal Justice Agency funded procedure codes with modifier HZ because these services are excluded from the capitation. Crisis Intervention services are considered emergency behavioral health services and do not require prior authorization but providers must follow current RRUMG. Employment related services that provide training and supports that are not job specific and have as their focus the development of skills to reduce or overcome the symptoms of mental illness that interfere with the individual s ability to make vocational choices, attain or retain employment can be provided under Skills Training and Development. These services should not be confused with Employment Assistance or Supported Employment allowed under the HCBS STAR+PLUS Waiver. Page 12

13 MCO Responsibilities MCOs: Must cover mental health rehabilitative and mental health targeted case management services effective September 1, 2014 Required to utilize the current DSHS utilization management guidelines Texas Resilience and Recovery (RRUMG) until September 2015 RRUMG for Adult Mental Health Services can be found at Texas Resilience and Recovery Utilization Management Guidelines - Adult Services (PDF) RRUMG Child and Adolescent Services can be found at Texas Resilience and Recovery Utilization Management Guidelines- Child and Adolescent Services (PDF) RRUMG will be redesigned to better integrate physical health and behavioral health care services for contract year 2015 The MCO is not responsible for providing any services listed in the RRUMG that are not covered RRUMG service packages may include counseling, pharmacological management and other Medicaid covered mental health services Maintain a qualified Network of entities, such as Local Mental Health Authorities (LMHAs) and multi-specialty groups, that employ providers of MH Rehab Services and Targeted Case Management. Provider entities must attest to the MCO that the organization has the ability to provide, either directly or through sub-contract, Members with the full array of RRUMG services. Page 13

14 Assessments Adults Needs and Strengths Assessment (ANSA) and the Child and Adolescent Needs and Strengths Assessment (CANS) will be leveraged in managed care for consistency in assessment for services across the indigent and Medicaid populations The MCO must ensure that providers use, and are trained and certified to administer, the ANSA and CANS assessment tools to recommend a level of care to MCO by using the current DSHS Clinical Management for Behavioral Health Services (CMBHS) web based system Providers must have a signed user agreement with DSHS to complete assessment in CMBHS MCOs and providers may contact Dr. John Lyons at John.Lyons@uottawa.ca for a coupon code to receive online training on the administration of ANSA and CANS assessment tools The MCO must also ensure that providers complete the MH Rehab and TCM Services Request Form and submit to MCO Level of Care information on form is tied to specific RRUMG service packages and hours Current authorizations are to be honored up to 90 days, to determine when reassessments for TCM and MH Rehab services must be completed, please refer to RRUMG Page 14

15 Contracting with Provider Entities The MCO must credential Provider entities, and any licensed Network Providers providing services through one of these entities, in accordance with the Contract The MCO is not required to credential Providers of Mental Health Rehabilitative Services and Targeted Case Management who are not licensed providers types enrolled in Medicaid, such as a Peer Provider (PP), Family Partner (FP), Community Services Specialist (CSSP), and Qualified Mental Health Professional for Community Services (QMHP- CS) if the QMHP is not also a Licensed Practitioner of the Healing Arts (LPHA) Page 15

16 Provider Qualifications and Supervisory Protocols Mental Health Rehabilitative Services Qualified Providers Qualified Mental Health Professionals for Community Services (QMHP-CS) the requirement minimums for a QMHP-CS are as follow Demonstrated competency in the work to be performed; and Bachelor's degree from an accredited college or university with a minimum number of hours that is equivalent to a major in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention; or RN An LPHA, as defined in Attachment A of the Contract, is automatically certified as a QMHP-CS. A CSSP, a Peer Provider, and a Family Partner, as those terms are defined in Attachment A of the Contract, can be a QMHP-CS if acting under the supervision of an LPHA. If a QMHP-CS is clinically supervised by another QMHP-CS, the supervising QMHP-CS must be clinically supervised by an LPHA Additionally, a Peer Provider must be a certified peer specialist, and an Family Partner must be a certified family partner Page 16

17 Provider Qualifications and Supervisory Protocols Mental Health Targeted Case Management Qualified Providers A qualified provider of mental health targeted case management must: Demonstrate competency in the work performed; and Possess a bachelor's degree from an accredited college or university with a minimum number of hours that is equivalent to a major in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention; or Be a Registered Nurse (RN) MCO is prohibited from establishing additional supervisory protocols with respect to the above-listed provider types MCO may not require the name of a performing provider on claims submitted to the MCO if that provider is not a type that enrolls in Medicaid (such as CSSPs, PPs, FPs, non-lpha QMHPs, and Targeted Case Managers) Page 17