The Louisiana Behavioral Health Partnership

Transcription

1 The Louisiana Behavioral Health Partnership Statewide Management Organization Provider Training Event February 2012

2 Agenda Overview Paul Dykes, Chief Executive Officer, Magellan Behavioral Health of Louisiana Service Description Manual Rusty Miller, Network Development OBH/CSoC Requirements Foley Nash, Children s System Administrator Eligibility and Covered Services Sarah Maloney, Sr. Director, Operations and Implementation; Matt Hall, Sr. IT Director; and Tim Hebert, IT Director Clinical Rebecca Procopio, Clinical Director; and Foley Nash, Children s System Administrator OBH Certification Rusty Semon, State of Louisiana Quality / Appeals Barbara Dunn, Director Program Innovation and Outcomes Claims Sarah Maloney, Sr. Director, IT Operations and Implementation; Matt Hall, Sr. IT Director; and Tim Hebert, IT Director Website Tracey Alfaro, Network Operations Manager Clinical Advisor Matt Hall, Sr. IT Director; and Tim Hebert, IT Director Questions and Answers Panel 2

3 Overview Presented by: Paul Dykes, Chief Executive Officer Magellan Behavioral Health of Louisiana Presented by: Paul Dykes, Chief Executive Officer Magellan Behavioral Health of Louisiana

4 Louisiana Behavioral Health Partnership Magellan Health Services will manage behavioral health services under contract to the Office of Behavioral Health in the Department of Health and Hospitals (OBH/DHH). This managed care system is known as the Louisiana Behavioral Health Partnership (LBHP). 4

5 Mission/Vision Magellan Health Services Leading diversified specialty health care management organization. Mission With a focus on care and respect, we apply clinical expertise to assist people during challenging times. We deliver innovative solutions to our customers, and collaborate with providers to positively influence the health and well-being of individuals and the affordability of care. Vision We are the premier partner in making quality health care more affordable, and innovating to bring clinical excellence into the lives of the people entrusted to our care. 5

6 Reliance on Partnership Magellan collaborates with governments, providers, national advocacy organizations, individuals and their families to design, manage and continually improve behavioral health systems for government agencies. Our partners include: Service providers to gain their unique perspective on public sector consumers' behavioral health needs and resources available to meet those needs. State and county/parish government agencies as they build, manage or transform their public mental health and substance abuse systems. Individuals and families who play a variety of critical roles including participating on our program advisory boards and quality improvement committees. National and local advocacy organizations that support and promote behavioral health and wellness for everyone. 6

7 Magellan Louisiana Care Management Center Senior Management Team Paul Dykes, CEO Open, Communications Administrator Mary Heywood, CFO Craig Coenson, CMO Open, VP System Transformation Deb Happ, COO (Interim) Tim Hebert, IS Administrator Sreela Pulukh, Medical Administrator Open, Care Management /Utilization Review Administrator Seth Kunen, QM Administrator Foley Nash, Children s System Administrator Russell Miller, Network Development Administrator J. Paula Turner, Claims/ Encounter Administrator Troy Rogers, Care Management Manager Mary Jones, Grievances and Appeals Administrator Kathleen Coenson, Adult System Administrator Susan Mittendorf, Network Management Administrator Stacie Zerangue, Care Management Manager Robert Blue, Race/Equity Administrator Latishia Anderson, Member Services Administrator Chris Boling, Care Management Manager Margaret Mitchell, Recovery/Resiliency Administrator Ra'quel Shavers, Training and Development Manager Open, Stakeholder Liaisons 7

8 Key Information Go-live date: March 1, 2012 Main office location: Satellite office location: Baton Rouge Shreveport Hours of Operation: 24/7 Provider Services Line:

9 Implementation Priorities Pre- March 1, 2012 Complete credentialing and contracting of providers Complete hiring Magellan of Louisiana staff Set up Magellan offices in Baton Rouge and Shreveport Train providers Share information on LBHP with community March 1, 2012 Ensure successful transition of care for members and their families Ensure providers get paid Focus on service quality and improved access to care Partner with Bayou Health around integrative care and collaborative protocols 9

10 LBHP Service Description Manual Presented by: Rusty Miller Network Development

11 Overview Louisiana Service Description Manual Where is the manual? Why a manual? What do providers need to know about the manual? 11

12 Manual is Located on DHH Website Louisiana Behavioral Health Partnership SMO Procurement Library LBHP SERVICES MANUAL (The information in this section is subject to change at any time. Please check frequently) LBHP Services Manual Introduction LBHP Services Manual Version 4 LBHP Services Manual Codes - Version 2 LBHP services manual and the LBHP services manual codes provide the universe of allowable services within the LBHP program. 12

13 View From Three Altitude Levels The Waivers and State Plan Amendments (SPA) create the authorities that allows the state to develop alternative services to the standard fee-for-service Medicaid program 1915(b) umbrella waiver implementing the LBHP 1915(c) CSoC services for children 1915(i) adults with serious mental illness The Service Description Manual (SDM) more concisely defines the allowable services within the LBHP program in Louisiana Services approved by Centers for Medicare & Medicaid Services that the LBHP is allowed to fund as of March 1, 2012 Licensing Standards describes services at the most detailed level for services requiring state license 13

14 Snapshot of the Service Description Manual The manual contains information on: Service definitions Provider qualifications Eligibility criteria Limitations/exclusions Provider types allowed to deliver specific services 14

15 Snapshot of the Service Description Manual Covered services - 8 sections Services for CSoC Children Parent/youth support & training Crisis intervention Respite Independent living/skills-building Case Conference for Adults and Children Face-to-face conferences for CSoC and 1915(i) adults 15

16 Snapshot of the Service Description Manual Treatment Planning Section 3.1 Wraparound facilitation for CSoC children Treatment Planning Section 3.2 CSoC-eligible children in regions not yet phased into CSoC Children with behavioral health needs in contact with other child-serving systems (OJJ, DCFS) not eligible for CSoC. Any individual with IV drug use, pregnant substance abuse users, substance-using women with dependent children or co-occurring disorders. Adults eligible for the 1915(i) HCBS services. 16

17 Snapshot of the Service Description Manual Behavioral Health Services Delivered by Unlicensed Individuals Psychosocial rehabilitation, community psychiatric support & treatment, crises intervention For 1915(i) adults and children meeting medical necessity criteria MHR, CMHC and school-based health centers Therapeutic group home Addiction services American Society of Addiction Medicine levels of care 17

18 Snapshot of the Service Description Manual Outpatient & Inpatient Hospitals Psychiatric Residential Treatment Facility (PRTF) Children under age 21, pre-certified by an independent team employed by the SMO Outpatient Therapy by Licensed Practitioners Individual, family, group outpatient psychotherapy and mental health assessment, evaluation and testing. Medical, psychiatrist, other licensed practitioner service 18

19 Service Description Manual Addendum Section Medicaid Medical Necessity Definition and EPSDT policy Exceptions Therapeutic Foster Care and Non-Medical Group Home Treatment services provided by and billed through other licensed practitioners and qualifying services 19

20 Service Description Manual Addendum Section Additional Service Criteria for Evidence-Based Practices (EBPs) Assertive community treatment adults with serious and persistent mental illnesses (SPMI) Multi-systemic therapy (MST) Homebuilders Functional family therapy (FFT) MST, Homebuilders, FFT target youth with significant externalizing behaviors, at high-risk of out-of-home placement and may be involved with multiple child-serving agencies (OJJ, DCFS) 20

21 Magellan and the Service Description Manual Magellan of Louisiana provider contracts are developed using the Service Manual Codes spreadsheet Magellan reimbursement schedules sent out with the contracts correlate to Service Manual Codes and rates Magellan can contract only with providers meeting requirements defined in the manual for specific services We look forward to partnership and dialogue with individual Louisiana providers 21

22 OBH/CSoC Requirements Presented by: Foley Nash Children s System Administrator

23 OBH/CSoC Wraparound Agency Certification Requirements 1. Education level/degree requirements 2. Work experience 3. Louisiana criminal history background check using fingerprints 4. Louisiana motor vehicle check and drug test 5. Wraparound training requirements 23

24 OBH/CSoC Wraparound Agency Certification Requirements 1. Completion of three-hour system of care/wraparound overview 2. Completion of three-day wraparound core training 3. Completion of wraparound practitioner training units 4. On-site coaching/mentoring 5. Practice observations 6. Child/family team meetings using team observation & document review measures 24

25 OBH/CSoC Wraparound Agency Certification Requirements 1. Education level/degree requirements 2. Work experience 3. Louisiana criminal history background check using fingerprints 4. Louisiana motor vehicle check and drug test 5. FSO training requirements 25

26 OBH/CSoC Wraparound Agency Certification Requirements Family support training will be developed to ensure the specific needs of the FSO providers are addressed. Ongoing training will include, but will not be limited to: 1. Fundamentals of providing family-driven services 2. Opportunities for coaching/mentoring 3. Observations using any pre-established protocols 26

27 OBH/CSoC Family Support Organization Certification Requirements Individual Provider Certification Decision Tree Do I need to be certified by OBH? Are you a Licensed Mental Health Professional? Are you Self Employed at least Part-Time? Yes / No You do not need to complete the Individual Certification Application You must complete the Individual Certification Application Yes / No You do not need to complete the Individual Certification Application Do you plan to provide Addiction Treatment and/or Treatment Planning? Yes / No Submit Individual Application with Section 1,2 3 and 4 completed along with required documentation to the OBH Certification Section Submit Individual Application with Section 1,2 and 4 completed to the OBH Certification Section 27

28 OBH/CSoC Family Support Organization Certification Requirements Organizational Provider Certification Decision Tree Do I need to be certified by OBH? Are you an Organization planning to credential with Magellan? Are you currently an OBH Clinic, LGE Clinic, MHR Agency, MST,FFT,ACT or Homebuilders service provider? Yes / No See Individual Provider Certification Decision Tree Do you have staff that will provide Addiction Treatment and/or Treatment Planning Service Yes / No Do you provide or intend to provide PSR,CPST,CI/ CS,TGH,Treatment Planning or Addiction Services? Yes / No Yes / No You must complete the Organizational Provider Certification Application You do not need to complete the Organizational Provider Certification Application You must complete the Organizational Provider Certification Application You do not need to complete the Organizational Provider Certification Application 28

29 Eligibility Presented by: Sarah Maloney, Sr. Director, Operations and Implementation Matt Hall, Sr. IT Director Tim Hebert, IT Director

30 Who Are the LBHP-eligible populations? Children There are two populations of children and youth eligible for LBHP services: Children and youth with behavioral health needs eligible for services from OJJ, DCFS, DHH and DOE Children and youth with significant behavioral health challenges or cooccurring mental illness and addictions in, or at risk of, out-of-home placements, eligible for the CSoC Out-of-home is defined as: Detention, secure care facilities, psychiatric hospitals, residential treatment facilities, developmental disabilities facilities, addiction facilities, foster care and alternative schools homeless, as identified by DOE 30

31 Who Are the LBHP-eligible populations? Adults Adults in need of addictions treatment. Adults with a functional behavioral health need, including: Individuals with acute stabilization needs Individuals with serious mental illness (federal definition of serious mental disorder) Individuals with major mental disorder Adults who have previously met the above criteria and need subsequent medically necessary services for stabilization and maintenance This includes adults with co-occurring disorders of mental illness and addictions 31

32 Eligibility Requirements by Payer Source State funding: Each Louisiana department has requirements for eligibility based upon its authorizing legislation and rules Other federal funding: Block grants and Substance Abuse and Mental Health Services Administration (SAMHSA) grants have unique requirements Medicaid eligibility: CMS and states each set rules for Medicaid eligibility: Eligibility categories (e.g., aged, blind, disabled) Income (e.g., eligibility based upon poverty level) State plan and waiver authorities have different eligibility requirements 32

33 How Will We Know Who Is Eligible for the LBHP? Each funding agent (Medicaid, OBH, DCFS, OJJ, DOE, etc.) is responsible for determining eligibility based upon their mandates Magellan, as the SMO, will manage eligibility: The eligibility rules and information on eligible individuals are provided to Magellan by each department Magellan tracks and manages department-based rules and maintains eligibility information through its information technology Magellan has different methods to track eligibility: Magellan website features Member Services call center Clinical Advisor the EBHR used by Magellan providers 33

34 What Are the Eligible Services for each Population? Services for each population vary depending on the funding source Focus today will be primarily on Medicaid services Some basics about Medicaid: State Plans and waivers identify broad service categories, e.g., substance abuse rehabilitation services, physician services, licensed practitioner services The goal is to keep the Medicaid services as broad as possible to allow states to implement evidence- and research-based practices without having to amend the state plan or waivers The State Plan does have to specify staff qualifications, typically as defined by the state, based upon state rules, with some guidance from CMS (e.g., licensure requirement) 34

35 Medicaid Service Categories and State-Level Service Definitions State manuals provide more detailed service information: Service definitions Billing codes/units of service Referral guidelines Today, we will focus on the service categories in the Medicaid State Plan and waiver authorities and their flexibility to provide cost-effective alternative services. 35

36 What Services Are Included in the Louisiana Medicaid State Plan? Medicaid State Plan basic services available to all Medicaid-eligible populations: Under the State Medicaid Plan, all Medicaid-eligible adults and children are eligible for the following medically necessary services: Services provided by psychiatrist Inpatient psychiatric care Emergency room care Substance abuse (addictions) rehabilitation services All Medicaid-eligible children are eligible for medically necessary early and periodic screening, diagnosis and treatment (EPSDT) services Non-Medicaid-eligible individuals may receive the above services through SGF, block grants and/or private insurance 36

37 LBHP Services by Eligibility Category Service Population Medicaid children CSoC children (Medicaid and non- Medicaid) Medicaid adults Medicaid adults eligible for the 1915(i) Medically needy CHIP in separate program OBH adults OBH children OJJ/ DCFS children Inpatient general Hospital Psychiatrists (Physician) X X X X X X X X X X X X X X X Psychiatric hospital X X Over age 65 X X Psychiatric residential treatment facility (PRTF) < age 21 Rehabilitation therapeutic group home Licensed mental health practitioners X X X X X X X X X X X X X 37

38 LBHP Services by Eligibility Category, cont. Service Population Medicaid children CSoC Medicaid Non- Medicaid children Medicaid adults Medicaid adults eligible for the 1915(i) OBH adults OBH children OJJ/ DCFS children Rehabilitation unlicensed CPST Psychosocial rehabilitation Crisis intervention Rehabilitation substance abuse 1915(c)/1915(b)(3) CSoC services Parent support and training Youth support and training Independent living skills building services Short term respite Crisis stabilization X X X X X X X X X X X X X X 1915(b)(3) case conference X X X X X X 38

39 Eligibility Verification Eligibility can be found in Clinical Advisor (CA) and on the Magellan provider website ( accessible via links on 39

40 Looking up Eligibility in Clinical Advisor Clinical Advisor is a web-based application provided as an electronic behavioral health record (EBHR) and practice management system to Magellan s contracted providers Clinical Advisor has lookup features for eligibility through any of Magellan s funding sources covering the entire LBHP 40

41 Clinical Advisor Eligibility Client Look-Up The user will be able to search for clients. In the example above, only the Last Name was entered to find members. Other search criteria elements could also be entered to limit the number of members returned. From this page, the user would double click on the member they want to choose. Providers can search for members using specific variables or combinations of variables to limit the search results. In the example above, only the Last Name was entered, which returns a list of members with the name entered. To select a member, the provider double-clicks the member name.. 41

42 Clinical Advisor Eligibility Client Look-Up cont. The Client Master page displays member demographic detail and features tabs across the top for more specific information about the member s coverage. 42

43 Clinical Advisor Eligibility Client Look-Up cont. One of the tabs of the Client Master give information regarding who is responsible for payment. Also included on this page is the Medicare and Medicaid ID information. One of the tabs of the Client Master gives information regarding who is responsible for payment. Also included on this page is the Medicare and Medicaid ID information. 43

44 Clinical Advisor Eligibility Client Look-Up cont. Once a member is located, the Client Packets page shows enrollment spans. In the example above, the member was active 9/1/2007 thru 10/5/2007; after a gap in coverage the coverage was reactivated on 10/23/

45 Looking up Eligibility by Signing in to MagellanHealth.com/provider is available to contracted Magellan providers It can be accessed through links on 45

46 Magellan Provider Website Eligibility Client Look-Up 46

47 Magellan Provider Website Eligibility Client Look-Up, continued 47

48 Magellan Provider Website Eligibility Client Look-Up, continued 48