MARYLAND MEDICAID: SUMMARY OF MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS

Transcription

1 MARYLAND MEDICAID: SUMMARY OF MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS Key Ppulatins Cvered Diagnsis Cvered Under Specialty Mental Prvided n FFS Basis Thrugh Value ptins Specialty Mental Prvided n FFS Basis Thrugh Value Optins (Based n diagnsis listed abve.) HealthChice Primary Adult Care Prgram FFS Enrllees Childless adults 19 and ver Nt cvered by Medicare Pregnant wmen Parents Children (including MCHP) Individuals with disabilities n SSI Individuals wh are dually eligible ( Duals ) fr bth Medicaid and Medicare Individuals with nursing hme stays ver 30 days Individuals age 65 and lder Individuals determined medically needy under a spend dwn categry Individuals in a limited-benefit family planning prgram Must have ne f the fllwing mental illness diagnses accrding t Internatinal Classificatin f Diseases, 9 th revisin : ; 299.9; ; ; ; 307.1; 307.3; ; ; ;311; ; ; ;332.1;333.1;333.82;333.90;333.92; Examples include individuals with diagnses such as schizphrenic disrder, md disrders, anxiety disrders, and persnality disrders prvided thrugh the public mental health system n a fee-frservice basis Hspital Residential treatment fr children and adlescents Individual and grup therapy with licensed mental health prfessinals, e.g., psychiatrists, psychlgists, cunselrs, etc. Clinical services at Outpatient Mental Health Centers r Federally Qualified Health Centers Limited medical labratry services; specifically, venipuncture cllectin f bld, therapeutic injectin See HealthChice benefit package, exemptins include: PAC des nt cver any inpatient benefits. PAC als des nt cver EPSDT services since the prgram is fr adults Duals - Medicare and Medicaid Eligible Medicare Part A Medicare nly cvers a ttal f 190 days spent in a psychiatric hspital fr an entire lifetime. If smene reaches that limit, Medicare may cver further inpatient mental health care in a general hspital but nt a psychiatric hspital. This rule nly applies t free-standing psychiatric facilities that are nt cnsidered a part f general hspitals.

2 Specialty Mental Prvided n FFS Basis Thrugh Value Optins (cnt d) Treatment and HealthChice Primary Adult Care Prgram FFS Enrllees EPSDT services fr children, such therapeutic nursery prgrams Mental health targeted case management Family psychtherapy and psycheducatin Psychiatric day treatment services such as partial hspitalizatin r intensive utpatient services Intensive services fr high needs cnsumers such as mbile r assertive cmmunity treatment Psychiatric rehabilitatin prgrams Psychlgical testing Institutin fr Mental Diseases (Maryland is nw participating in a three-year demnstratin t prvide this services fr adults up t age 64 in private institutins. ) paid fr by the MCO (prviders d nt need t be in MCO netwrk) Physician management f buprenrphine and nalxne; Cmprehensive substance abuse assessment (H0001) Individual, family, r grup cunseling (H0004, H0005) Intensive utpatient treatment (H0015) Methadne maintenance (H0020) Hspital- and cmmunity-based detxificatin Buprenrphine and ther SA prescriptins as allwed n MCO frmularies PAC des nt cver Treatment services rendered in hspitals r HSCRC rate regulated hspital utpatient clinics. Medicare Part B Individual and grup psychtherapy Family psychtherapy (with yu present) fr yur treatment Certain lab and diagnstic tests Psychiatric evaluatins Medicatin management Medicaid Medicaid-cvered services nt cvered by Medicare Medicare cinsurance (Value Optins is nt invlved in these services) Nn-Duals See benefit under HealthChice Duals - Medicare and Medicaid Eligible Medicare Part A Medicare general hspital services Medicare Part B helps pay fr utpatient substance abuse treatment services frm a clinic r hspital utpatient department. Methadne may be cvered if prvided t hspital inpatients but nt prvided in utpatient clinics. Medicaid Medicaid-cvered services nt cvered by Medicare Medicare cinsurance Nn-Duals See benefit under HealthChice

3 Reimbursement HealthChice Primary Adult Care Prgram FFS Enrllees Maryland increased fees n January 1, MCOs are required t pay at least the fee-fr-service rates listed belw. H $142 per assessment H $20 per 15 minute increment H $39 per sessin H $125 per sessin (n mre than 4 per week) H $80 per week Specialty Mental Health Fr a cmplete list f billing cdes and reimbursement rates, please visit: _23_08.pdf Under the Mental Health Parity and Addictin Equity Act f 2008, private health plans have t cver bth physical and mental health services equally. Medicare, which cvered mental health services at 50 percent rather than the 80 percent rate fr physical treatment, wasn't required t abide by the law. The Medicare Imprvements fr Patients and Prviders Act f 2008 changed that. Medicare is gradually increasing the percentage it cvers fr mental health services, until in 2014 it will reach 80 percent. (In 2012, the prgram cvers 60 percent.)

4 NON-MEDICAID REIMBURSABLE SERVICES: MENTAL HEALTH AND SUBSTANCE ABUSE Nn-Medicaid Reimbursable Mental Health Supprted emplyment Respite care Residential crisis services Peer supprt and family educatin and supprt Residential rehabilitatin services Preventin/Educatin in Cmmunity/Schls Envirnmental Strategies that includes: Scial Media Campaigns Cmmunities Mbilizing Fr Change Against Alchl (CMCA) Infrmatin Disseminatin services. EBP prgrams (BSFT/FFT) Cmmunity Reinfrcement and Family Training (CRAFFT) Family Scial Drinkers Educatin Acupuncture Evaluatins (Legal) Evaluatins/Assessments that d nt lead t a diagnsis ( Rule Out, nt cvered by MA) Sme Drug Testing Infrmatin/Referral Level.5 Early Interventin Care Crdinatin Cntinuing Care Access t Recvery Residential Treatment: Lw Intensity III.1 Medium Intensity III.3 High Intensity III.5 Medically Mnitred Inpatient III.7 (fr adults) Nn-Hspital Detxificatin Alternative Prgrams Anger management

5 Nn-Medicaid Reimbursable Mental Health Curt Diversin Prgram (State s Attrney) Hspital Diversin Prgram 2 Adult Drug Curts (Circuit Curt and District Curt) Curt Liaisn Curt-rdered Status Mnitring Drug Curt Case Manager Juvenile Drug Curt Alternative Schl (schl based) Integrated Dual Diagnsis Treatment team meetings, utreach & case management, and engagement grup Jail-based level I and II treatment All "behind the wall" prgrams Clinical assessment and triage f in-mates int specialty MH r addictin units Cmmunity Re-entry frm jail (mental health and addictin treatment placements, referrals, supervisin) Re-entry Family Recvery Curt Curt Evaluatins (HG-505/507) Gambling Cunseling Tbacc Assessment/Referral (when prvider is nt a physician) Recvery riented Systems f Care: Recvery Husing Recvery Cmmunity Center Peer Supprt Future t include: AVATAR (n-line) Cunseling