Health Plans Pay for Court- Ordered Mental Health Services

Transcription

1 Bulletin December # , 2001 Minnesota Department of Human Services # 444 Lafayette Rd. # St. Paul, MN OF INTEREST TO! County Directors! Community Mental Health Centers! Contracted MH Case Mgmt. Providers! Regional Treatment Centers! Adult MH Initiative Contacts! Local Mental Health Advisory Council Chair! Children s MH Collaboratives! Tribal Health Directors! Rule 29 Clinics! Rule 36 Programs ACTION Counties, pre-petition screeners, case managers and providers will need to work more closely with health plans. DUE DATE Health Plans Pay for Court- Ordered Mental Health Services TOPIC New legislation requires health plans to pay for court-ordered mental health services. The Attorney General s settlements with Blue Cross and other plans include chemical dependency treatment and additional mental health requirements. PURPOSE This is an opportunity for counties and providers to obtain additional revenue and to improve continuity of care for their clients. CONTACT If you have questions about the legislation: John Zakelj (651) john.zakelj@state.mn.us If you have a complaint about an HMO: Minnesota Department of Health at (800) If you have a complaint about an indemnity plan: Minnesota Department of Commerce at (800) If you have a complaint about a PMAP, PGAMC or MinnesotaCare plan: Ombudsman for State Managed Health Care Programs at (800) (non-metro) or (metro). SIGNED Varies by type of health plan (see page 3). MARIA R. GOMEZ Assistant Commissioner Continuing Care MARY B. KENNEDY Assistant Commissioner Health Care

2 Page 2 BACKGROUND The 2001 Legislature made significant changes relating to health plans' responsibility for mental health services, especially court-ordered services. While the 2001 Session was proceeding, the State Attorney General worked out a related settlement with Blue Cross. The settlement applies to all health plans issued by Blue Cross Blue Shield and its affiliates and subsidiaries. The settlement was effective June 2001, and has a number of provisions that go beyond the above legislation. The Attorney General is still negotiating with other plans, including Health Partners and Medica, to determine which terms of the Blue Cross settlement (in addition to what is required by the legislation) will apply to the other plans. This bulletin was developed in cooperation with the Departments of Health and Commerce. Similar bulletins are being issued by the Department of Health (to HMOs) and by the Department of Commerce (to indemnity plans). LEGAL REFERENCES A complete copy of the legislation is attached as Appendix A, and is also available on the Internet at under Laws of 2001, First Special Session, SF4 First Engrossment (also known as Chapter 9), Art. 9, Sec. 1-3, 20, 28 and 47. The text of the Blue Cross settlement is on the Web at: ACTION REQUESTED Counties, pre-petition screeners, case managers and providers will need to work more closely with health plans. SPECIAL NEEDS This information is available in other forms to people with disabilities by contacting us at (voice), or contact us through the Minnesota Relay Service at (TTY) or (speech-to-speech relay service).

3 Page 3 Payment for Court-ordered Mental Health Services (62Q.535) All fully insured health plans, including managed care and indemnity plans, must pay for court-ordered mental health services under the following circumstances:! the services are otherwise covered by the plan; and! the court s order is based on a behavioral care evaluation performed by a licensed psychiatrist or a doctoral level licensed psychologist, which includes a diagnosis and an individual treatment plan for care in the most appropriate, least restrictive environment; and! the care is provided by a participating provider of the health plan company; or by another provider if appropriate care is not available through the plan, or if another provider is required by state law or rule. This court-ordered coverage must not be subject to a separate medical necessity determination by a health plan company under its utilization review procedures. Payment for Clinical Evaluation The health plan must pay for the clinical evaluation used by the court if it is performed by a health plan participating provider. Effective Dates for Above Provisions The above provisions are effective for commercial contracts issued or renewed on or after July 1, This means that for most commercial plans the above requirement will take effect 1/1/02. For DHS funded prepaid plans (such as PMAP), the law is effective July 1, DHS will provide health plans with additional funding appropriated by the Legislature for this purpose retroactive to July 1, Definition of Court-ordered Under the Commitment Act, the term court-ordered mental health services includes mental health services which are provided as part of: a court hold, any type of commitment (which may include an order for early intervention), a stay of commitment, a continuance, or a revocation of a provisional discharge. However, the above legislation is not limited to the Commitment Act, since it refers to mental health services ordered by a court of competent jurisdiction. As long as the above criteria are met, this could also include mental health services which are ordered by a juvenile court for a child who is adjudicated as needing protection or services, mental health services which may be ordered by a

4 Page 4 criminal court as a condition of probation, or other situations in which a court of competent jurisdiction has included provision of, or participation in, mental health services as a condition in its findings. Coverage for Antipsychotic Drugs (62Q.527) Effective January 1, 2002, as contracts issue or renew, all fully insured health plans that provide prescription drug coverage must cover antipsychotic drugs regardless of the plans s formulary if the health care provider certifies that the prescribed drug will best treat the patient s condition. In addition, enrollees receiving a prescribed drug to treat a diagnosed mental illness or emotional disturbance may continue to receive the prescribed drug for up to one year without the imposition of special payment requirements, when a health plan s drug formulary changes or an enrollee changes health plans and the medication has been shown to effectively treat the patient s condition. Attorney General Settlements Health plans issued by BlueCross Blue Shield and its affiliates and subsidiaries are also covered by a settlement with the Attorney General, which was effective June 2001, and which has a number of provisions that go beyond the above legislation. This includes Blue Plus and First Plan of Minnesota. One significant difference is that the settlement includes chemical dependency treatment, whereas the above legislation does not. The text of the BlueCross Blue Shield settlement can be found at The Attorney General is still negotiating with other plans, such as Health Partners and Medica, to determine which terms of the Blue Cross settlement (in addition to what is required by the legislation) will apply to the other plans. Complaint Numbers Complaints about potential problems in compliance with this law will be investigated through the following: For state-regulated indemnity insurers and Blue Cross: Minnesota Department of Commerce (800) For state-regulated health maintenance organizations: Minnesota Department of Health (800)

5 Page 5 For state managed care public programs, including PMAP, PGAMC or MinnesotaCare plans: Ombudsman for State Managed Health Care Programs (800) (non-metro) or (metro). If you are not sure which of the above numbers to call, check the back of your client s health insurance card. If you do not see any of the above numbers, the plan may come under the Department of Commerce number above, or it may be a self-insured plan. Self-insured plans are typically provided to employees of large corporations, and are not subject to state regulation. Applicability This legislation does not apply to self-insured plans. However, although health plans for state employees are technically self-insured, M.S. 43A.22 (b), 43A.23, subd.1,and subd.2(b) require all state employee health plans to comply with state legislation. This legislation does not apply to Medical Assistance fee-for-service coverage. Implementation Steps for Counties and Providers 1. Training. In order to take full advantage of these new laws, counties and affected providers must inform their staff and participating entities. DHS is working with the Ombudsman for Mental Health and Mental Retardation to develop training for counties and providers. 2. Coordination with Health Plans. Counties and providers need to determine which clients are covered by which health plans. Even if court-ordered services are not involved, it is good practice to coordinate social and mental health services with any medical services being provided by the plan. In many cases, the client s social and mental health services may be covered by the plan, and reimbursement may be feasible. Note that, in most cases, the law requires counties and mental health agencies to obtain the client s consent to share mental health data. As soon as a county or mental health provider becomes aware that a client may need court-ordered services, the agency should contact the person s health plan. In some cases, the plan may be willing to pay for services which would not otherwise be covered if the plan determines that the services may be a cost-effective alternative to covered services. Note the following excerpt from the bulletins issued by the Departments of Health and Commerce to HMOs and indemnity plans:

6 Page 6 We expect managed care organizations to work more closely with their enrollees and mental health benefit managers to develop voluntary, community based treatment which could be a cost effective alternative to court-ordered treatment. Managed care organizations should participate in the pre-petition screening and commitment process to help develop an individual treatment plan for care in the most appropriate, least restrictive environment. 3. Coordination with Courts. The specific nature of a county s or provider s involvement with court procedures will depend on the type of legal proceeding. If a petition is filed for commitment, the county s pre-petition screening unit must conduct an investigation and prepare a report for the court. Legislation enacted prior to 2001 requires that this investigation include seeking input from the proposed patient's health plan company to provide the court with information about services the enrollee needs and the least restrictive alternatives (See M.S. 253B.07, Subd. 1 (a) (v).)

7 Page 7 Appendix A - Text of 2001 Legislation Relating to Health Plans and Court-Ordered Mental Health Services Laws of 2001, First Special Session, Chapter 9 (SF4), Art. 9 Section 1. [62Q.471] [EXCLUSION FOR SUICIDE ATTEMPTS PROHIBITED.] (a) No health plan may exclude or reduce coverage for health care for an enrollee that is otherwise covered under the health plan, on the basis that the need for the health care arose out of a suicide or suicide attempt by the enrollee. (b) For purposes of this section, "health plan" has the meaning given in section 62Q.01, subdivision 3, but includes the coverages described in section 62A.011, clauses (7) and (10). [EFFECTIVE DATE.] This section is effective January 1, 2002, and applies to contracts issued or renewed on or after that date. Sec. 2. [62Q.527] [COVERAGE OF NONFORMULARY DRUGS FOR MENTAL ILLNESS AND EMOTIONAL DISTURBANCE.] Subdivision 1. [DEFINITIONS.] (a) For purposes of this section, the following terms have the meanings given to them. (b) "Emotional disturbance" has the meaning given in section , subdivision 15. (c) "Mental illness" has the meaning given in section , subdivision 20, paragraph (a). (d) "Health plan" has the meaning given in section 62Q.01, subdivision 3, but includes the coverages described in section 62A.011, subdivision 3, clauses (7) and (10). Subd. 2. [REQUIRED COVERAGE FOR ANTIPSYCHOTIC DRUGS.] (a) A health plan that provides prescription drug coverage must provide coverage for an antipsychotic drug prescribed to treat emotional disturbance or mental illness regardless of whether the drug is in the health plan's drug formulary, if the health care provider prescribing the drug: (1) indicates to the dispensing pharmacist, orally or in writing according to section , that the prescription must be dispensed as communicated; and (2) certifies in writing to the health plan company that the health care provider has considered all equivalent drugs in the health plan's drug formulary and has determined that the drug prescribed will best treat the patient's condition. (b) The health plan is not required to provide coverage for a drug if the drug was removed from the health plan's drug formulary for safety reasons. (c) For drugs covered under this section, no health plan company that has received a certification from the health care provider as described in paragraph (a), may: (1) impose a special deductible, co-payment, coinsurance, or other special payment requirement that the health plan does not apply to drugs that are in the health plan's drug formulary; or (2) require written certification from the prescribing provider each time a prescription is refilled or renewed that the drug prescribed will best treat the patient's condition.

8 Page 8 Subd. 3. [CONTINUING CARE.] (a) Enrollees receiving a prescribed drug to treat a diagnosed mental illness or emotional disturbance, may continue to receive the prescribed drug for up to one year without the imposition of a special deductible, co-payment, coinsurance, or other special payment requirements, when a health plan's drug formulary changes or an enrollee changes health plans and the medication has been shown to effectively treat the patient's condition. In order to be eligible for this continuing care benefit: (1) the patient must have been treated with the drug for 90 days prior to a change in a health plan's drug formulary or a change in the enrollee's health plan; (2) the health care provider prescribing the drug indicates to the dispensing pharmacist, orally or in writing according to section , that the prescription must be dispensed as communicated; and (3) the health care provider prescribing the drug certifies in writing to the health plan company that the drug prescribed will best treat the patient's condition. (b) The continuing care benefit shall be extended annually when the health care provider prescribing the drug: (1) indicates to the dispensing pharmacist, orally or in writing according to section , that the prescription must be dispensed as communicated; and (2) certifies in writing to the health plan company that the drug prescribed will best treat the patient's condition. (c) The health plan company is not required to provide coverage for a drug if the drug was removed from the health plan's drug formulary for safety reasons. Subd. 4. [EXCEPTION TO FORMULARY.] A health plan company must promptly grant an exception to the health plan's drug formulary for an enrollee when the health care provider prescribing the drug indicates to the health plan company that: (1) the formulary drug causes an adverse reaction in the patient; (2) the formulary drug is contraindicated for the patient; or (3) the health care provider demonstrates to the health plan that the prescription drug must be dispensed as written to provide maximum medical benefit to the patient. [EFFECTIVE DATE.] This section is effective January 1, 2002, and applies to contracts issued or renewed on or after that date. Sec. 3. [62Q.535] [COVERAGE FOR COURT-ORDERED MENTAL HEALTH SERVICES.] Subdivision 1. [MENTAL HEALTH SERVICES.] For purposes of this section, mental health services means all covered services that are intended to treat or ameliorate an emotional, behavioral, or psychiatric condition and that are covered by the policy, contract, or certificate of coverage of the enrollee's health plan company or by law. Subd. 2. [COVERAGE REQUIRED.] (a) All health plan companies that provide coverage for mental health services must cover or provide mental health services ordered by a court of competent jurisdiction under a court order that is issued on the basis of a behavioral care evaluation performed by a licensed psychiatrist or a doctoral level licensed psychologist, which includes a diagnosis and an individual treatment plan for care in the most appropriate, least restrictive environment. The health plan company must be given a copy of the court order and the

9 Page 9 behavioral care evaluation. The health plan company shall be financially liable for the evaluation if performed by a participating provider of the health plan company and shall be financially liable for the care included in the court-ordered individual treatment plan if the care is covered by the health plan and ordered to be provided by a participating provider or another provider as required by rule or law. This court-ordered coverage must not be subject to a separate medical necessity determination by a health plan company under its utilization procedures. (b) A party or interested person, including a health plan company or its designee, may make a motion for modification of the court-ordered plan of care pursuant to the applicable rules of procedure for modification of the court's order. The motion may include a request for a new behavioral care evaluation according to this section. [EFFECTIVE DATE.] This section is effective July 1, 2001, and applies to contracts issued or renewed on or after that date. Sec. 20. Minnesota Statutes 2000, section 253B.02, subdivision 10, is amended to read: Subd. 10. [INTERESTED PERSON.] "Interested person" means: (1) an adult, including but not limited to, a public official, including a local welfare agency acting under section , and the legal guardian, spouse, parent, legal counsel, adult child, next of kin, or other person designated by a proposed patient; or (2) a health plan company that is providing coverage for a proposed patient. Sec. 28. Minnesota Statutes 2000, section 253B.045, subdivision 6, is amended to read: Subd. 6. [COVERAGE.] A health plan company must provide coverage, according to the terms of the policy, contract, or certificate of coverage, for all medically necessary covered services as determined by section 62Q.53 provided to an enrollee that are ordered by the court under this chapter. (a) For purposes of this section, "mental health services" means all covered services that are intended to treat or ameliorate an emotional, behavioral, or psychiatric condition and that are covered by the policy, contract, or certificate of coverage of the enrollee's health plan company or by law. (b) All health plan companies that provide coverage for mental health services must cover or provide mental health services ordered by a court of competent jurisdiction under a court order that is issued on the basis of a behavioral care evaluation performed by a licensed psychiatrist or a doctoral level licensed psychologist, which includes a diagnosis and an individual treatment plan for care in the most appropriate, least restrictive environment. The health plan company must be given a copy of the court order and the behavioral care evaluation. The health plan company shall be financially liable for the evaluation if performed by a participating provider of the health plan company and shall be financially liable for the care included in the court-ordered individual treatment plan if the care is covered by the health plan company and ordered to be provided by a participating provider or another provider as required by rule or law. This courtordered coverage must not be subject to a separate medical necessity determination by a health plan company under its utilization procedures.

10 Page 10 Sec. 47. Minnesota Statutes 2000, section 260C.201, subdivision 1, as amended by Laws 2001, chapter 178, article 1, section 16, is amended to read: Subdivision 1. [DISPOSITIONS.] (a) If the court finds that the child is in need of protection or services or neglected and in foster care, it shall enter an order making any of the following dispositions of the case: (1) place the child under the protective supervision of the responsible social services agency or child-placing agency in the home of a parent of the child under conditions prescribed by the court directed to the correction of the child's need for protection or services: (i) the court may order the child into the home of a parent who does not otherwise have legal custody of the child, however, an order under this section does not confer legal custody on that parent; (ii) if the court orders the child into the home of a father who is not adjudicated, he must cooperate with paternity establishment proceedings regarding the child in the appropriate jurisdiction as one of the conditions prescribed by the court for the child to continue in his home; (iii) the court may order the child into the home of a noncustodial parent with conditions and may also order both the noncustodial and the custodial parent to comply with the requirements of a case plan under subdivision 2; or (2) transfer legal custody to one of the following: (i) a child-placing agency; or (ii) the responsible social services agency. In placing a child whose custody has been transferred under this paragraph, the agencies shall make an individualized determination of how the placement is in the child's best interests using the consideration for relatives and the best interest factors in section 260C.212, subdivision 2, paragraph (b); or (3) if the child has been adjudicated as a child in need of protection or services because the child is in need of special treatment and services or care for reasons of physical or mental health to treat or ameliorate a physical or mental disability, the court may order the child's parent, guardian, or custodian to provide it. The court may order the child's health plan company to provide mental health services to the child. Section 62Q.535 applies to an order for mental health services directed to the child's health plan company. If the health plan, parent, guardian, or custodian fails or is unable to provide this treatment or care, the court may order it provided. Absent specific written findings by the court that the child's disability is the result of abuse or neglect by the child's parent or guardian, the court shall not transfer legal custody of the child for the purpose of obtaining special treatment or care solely because the parent is unable to provide the treatment or care. If the court's order for mental health treatment is based on a diagnosis made by a treatment professional, the court may order that the diagnosing professional not provide the treatment to the child if it finds that such an order is in the child's best interests; or (The rest of this subdivision is unchanged)