Behavioral Health Benefits. Cortney Shaw Behavioral Health Manager
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1 Behavioral Health Benefits Cortney Shaw Behavioral Health Manager 0
2 Behavioral Health Services CalOptima s Behavioral Health Services Medi-Cal Duals (Medi-Cal/ Medicare) Orange County Mental Health Plan (MHP) (as of 7/1/15, CalOptima no longer administers this program, but SPMI services continue unchanged with the same number) Managed Care Plan (MCP) OneCare Connect / OneCare OC MHP Access Line (Beacon Health Strategies) CalOptima Behavioral Health (Beacon Health Strategies) Windstone Behavioral Health
3 Medi-Cal Expansion The Affordable Care Act ensures that all Medi-Cal health plans offer a comprehensive package of services, known as essential health benefits Essential health benefits must include: 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental Health and Substance Use Disorder Services, including Behavioral Health Treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services (including oral and vision care) 2
4 Medi-Cal Behavioral Health (BH) Benefits The following BH benefits are available through CalOptima: Individual and group psychotherapy Psychological testing to evaluate a mental health condition Outpatient services to monitor drug therapy Psychiatric consultation Screening, Brief Intervention and Referral to Treatment (SBIRT) provided in a primary care setting Specialty Mental Health Services are provided by the Orange County Mental Health Plan 3
5 Not Covered Under BH Benefits Mental health services for relational problems are not covered, including counseling for couples or families for conditions listed as relational problems* * As defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM) 4
6 Mental Health and Substance Use Disorder Services Medi-Cal Managed Care Plan (MCP) for mild to moderate (CalOptima) MCP services beginning 1/1/14 MH services (evaluations, psychotherapy and collateral) Coordination of care (no CM) Psychiatric consultation for medication management Psych testing when clinically indicated to evaluate MH condition Outpatient laboratory Medications (anti-psychotic drugs are covered by Medi-Cal FFS) Screening and Brief Intervention (SBIRT) in Primary Care Office County Mental Health Plan for SPMI (County) Specialty MH Services before and now MH services (assessments, therapy, rehabilitation and collateral) Targeted case management CMH psychiatrists Crisis intervention and stabilization Therapeutic behavior services Residential Services Adult residential Tx services Inpatient Services Psychiatric hospital & pro fees Crisis residential Tx services Fee-for-Service Psychiatrists Typically moderate severity Lower level of care for engaged members in the Recovery Model Drug Medi-Cal County Alcohol and Other Drug Programs (AOD) Drug Medi-Cal Providers Outpatient Intensive outpatient Narcotic treatment program Direct or access line possible Inpatient detoxification services County AOD Providers Residential Residential drug-free detox Outpatient Intensive outpatient OC LINKS access line NO Excluded Diagnoses Dementias Psychiatric consultation Mental Retardation Coordinate with Regional Center Autism (including new ABA as of 9/15) Mild to Moderate mental illness Helping members Reducing medical utilization (IC) Excluded Diagnoses Dementias Mental Retardation (Intellectual Disability Disorder DSM 5) Autism Mild to Moderate mental illness Often not sufficient impairment to receive services SBIRT Referral for treatment is a skill Treatment portion of SBIRT by AOD 50 Mild Mild/Moderate Moderate/Severe Severe/Acute
7 Medi-Cal BH Services Specialty Mental Health Services: County Mental Health Plan Severe/Acute (including psychiatric hospital and emergency services) Moderate Non-Specialty Mental Health Services: CalOptima (Beacon Health Strategies) Moderate (outpatient services only) Mild 6
8 Behavioral Health Treatment (BHT) for Autism Behavioral Health Treatment (BHT) is the use of behavioral techniques (e.g., positive reinforcement, prompting, shaping, etc.) to bring about meaningful and positive change in behavior A treatment program is customized based on the person s skills, needs, interests, preferences and family situation Treatment can help foster basic skills (e.g., looking, listening and imitating) and complex skills (e.g., reading, conversing and understanding another person s views) The goal is to develop or restore, to the maximum extent practicable, the functioning of an individual with Autism Spectrum Disorder (ASD) 7
9 Criteria for BHT Services Is under 21 years of age Has an Autism Spectrum Disorder (ASD) diagnosis Exhibits the presence of excesses and/or deficits of behaviors that significantly interfere with home or community activities Is medically stable and without a need for 24-hour medical/nursing monitoring Had a comprehensive diagnostic evaluation that indicates evidence-based BHT services are medically necessary Ordered by a licensed physician or developed by a licensed psychologist 8
10 CalOptima BHT Coverage Medically necessary Requires prior authorization Delivered in accordance with the member s CalOptima-approved treatment plan Treatment plan is reviewed no less than every six months Members currently receiving BHT at Regional Center of Orange County (RCOC) will continue to receive BHT at RCOC until the state develops a transition plan 9
11 Referral for Medi-Cal BH Services Call CalOptima Behavioral Health at: For screening and referral to mental health services. This number is available 24 hours a day, 7 days a week. TTY/TDD:
12 Referral Process Referral to CalOptima Behavioral Health for Mental Health Screening (by PCP, county programs, community, self, etc.) Medi-Cal Eligibility Verification Screening by Licensed Clinician Referral to Mental Health Services (as medically necessary) 11
13 OneCare/OneCare Connect BH Benefits Inpatient and Outpatient Behavioral Health Care Case Management Services Skilled Nursing Facility, Board and Care, Alzheimer Unit Consultations Acute Psychiatric Hospital Coverage Specialized use of Psych SNF s Psychiatric Conservatorships LPS 24x7 Emergency Coverage Differences Between OneCare & OneCare Connect OneCare Special Needs Plan (SNP) 18 and Older OneCare Connect- Duals Demonstration 21 and Older 12
14 Referral for OneCare BH Services Call Windstone Behavioral Health at: For screening and referral to mental health services. This number is available 24 hours a day, 7 days a week. TTY/TDD:
15 14
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