Accessing Behavioral Health Services

1. Accessing Behavioral Health Services Rhonda Cox, HSP-PA Sr. Director of Care Coordination Smoky Mountain Center September 7, 2012

2. What to Expect • Brief overview of differences between LMEs & MCOs • Brief overview payer sources & what that means for the families we serve • The parameters around service authorization & appeals • Some extra details to use when you might need a reference point

3. Background What’s the Difference between an LME & MCO?

4. Alphabet Soup • LME=Local Management Entity • MCO=Managed Care Organization • LME’s are responsible for managing state funded services to individuals who have no insurance & providing access to services to individuals who have Medicaid. • LME’s are being required to transform or merge into MCO’s • MCO’s are responsible for managing state funded & Medicaid services

5. Management means • Contracting with service providers • Linking consumers who have no insurance or Medicaid insurance to services • Paying for services defined or approved by NC DMA for Medicaid Services or DMHDDSAS for state-funded services • Monitoring Services • Developing services where there are gaps • Ensuring services are appropriate & and medically necessary • Managing costs

6. Management Tools • Care coordination • Flexible rate setting • Managing the provider network • Utilization management (review & authorization)

7. Medicaid Waiver: What is it? • A “waiver” allows for approved alternate services from standard Medicaid services. • A Medicaid Recipient is entitled to both State plan benefits & waiver services if they are not duplicative • MCO’s are implementing the Home & Community Based Supports (HCBS) (b) & (c) waivers (an expansion of a previous NC waiver through PBH) • The HCBS program permits NC to furnish an array of home & community based supports that assist Medicaid recipients to live in the community & avoid institutionalization

8. Medicaid Waiver Goals • Improve access to care • Predictable Medicaid costs • Combine management of State & Medicaid services funds at community level • Increase consistency & efficiency

9. Goals Continued • Support purchase & delivery of best practice • Ensure services are managed & delivered within a quality management framework • Empower the LME-MCO to build partnerships with consumers, providers and community stakeholders to provide a more responsive system of community care

10. Medicaid, Medicare, Private Insurance, No Insurance Who is eligible for what when?

11. Services Available-Medicaid • State Plan Medicaid Services including medical & behavioral health • Clinical Assessment (Master’s level clinician or higher) • Diagnostic Assessment (Doctoral level clinician) • Psychological Evaluation (Master’s level or Doctoral Level Psychologist) that includes testing • Medication Management • Basic Benefit (traditional outpatient treatment) • TCM if approved through EPSDT • Enhanced Services (intensive community based team services such as ACTT or IIH) • Residential Placement (TFCPRTF) • Behavioral Health Crisis Services • Behavioral Health Inpatient Services

12. MH/SA Targeted Case Management • TCM Functions: • Assistance with PCP • Linking • Referral • Monitoring • Only available through EPSDT=Early & periodic screening • If eligible, Medicaid recipients ages 3-21 • If eligible, Health Choice recipients ages 6-18 • Eligibility determined by: • Comprehensive Clinical Assessment • Primary MH or SA diagnosis • Multiple agency involvement

13. Services Available-Medicare • Medical & Behavioral Health Services • Clinical Assessment • Medication Management • Individual & Group Treatment • Mobile Crisis • Partial Hospitalization & Inpatient Treatment Services • MH or SA Treatment Services must be provided by an LCSW, PhD or PsyD

14. Services Available-State Funds • Clinical Assessment • Medication Management • Some traditional outpatient therapy (primarily group) • Very limited Enhanced Services • This is an LME-MCO specific decision based on UM planning • Mobile Crisis • State Facility Inpatient • *Forensic Screenings & Multidisciplinary Evaluations (not part of LME-MCO Level of Care but available) State funds are limited by available funds & not an entitlement

15. Private Insurance • Based on individual’s plan & network • Typically includes: • Medication Management • Individual or Group Counseling • In cases where a service may not be covered by private insurance, SOME LMEs & MCOs, may cover some enhanced services covered by the State-Funded Benefit Plan

16. What’s Not Covered • Targeted Case Management for adults (22+) • Transportation or transportation time • Capacity to Parent Evaluations • Anger Management Classes • DUI Classes • Offender Services*

17. Other Factors impacting Access to Services • Availability of a qualified provider organization • Provider is not contracted within home network • Service not supported by population • Transportation • Medical Necessity

18. Medical Necessity • “to correct or ameliorate a defect, physical or mental illness, or a condition” [health problem]; • The provider must document how a particular service, product, or procedure will correct, improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. • http://www.ncdhhs.gov/dma/mp/8a.pdf

19. What helps define Medical Necessity? • Service Definitions • http://www.ncdhhs.gov/dma/mp/index.htm (See Behavioral Health Policies 8A-8N) • TCM exists for LMEs but no longer a service definition for MCOs • CAP MRDD Services exist for LMEs/Innovations for MCOs • Assessment Tools • CALOCUS for Children & Adolescents (MH, SA or IDD) • LOCUS for Adults (MH) • ASAM for Children & Adults (SA) • SNAP or SIS for Children or Adults with IDD • Concrete information regarding specific behaviors or symptoms that support diagnosis or need for services

20. Rules around Medicaid Services • 8A, Enhanced Mental Health and Substance Abuse Services(8/1/11) • 8B, Inpatient Behavioral Health Services(8/1/07) • 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers(1/1/12) • 8D-1, Psychiatric Residential Treatment Facilities for Children under the Age of 21(8/1/12) • 8D-2, Residential Treatment Services(8/1/12) • 8E, Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities(8/1/12) • 8I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the under-21 Population(3/12/12) • 8J, Children's Developmental Service Agencies (CDSAs)(8/1/12) • 8L, Mental Health/Substance Abuse Targeted Case Management(7/30/10; eff. 7/1/10, 9/1/12) • 8M, Community Alternatives Program for Persons with Mental Retardation and Developmental Disabilities (CAP-MR/DD)(7/1/10) • 8N, Intellectual and Developmental Disabilities Targeted Case Management(6/1/11) • 8-O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders(3/12/12)

21. What Does not determine Medical necessity • A recommendation from the Child & Family Team • A Court Order • A need for out of home placement not specifically related to the child’s diagnosis & treatment needs • Criminal behavior of children (excluding sexual offending behavior) or adults

22. Connecting people to services • If a person has Medicaid, Medicare or no insurance, have them call the 24/7/365 toll-free access number to your local MCO or LME • They will be asked to provide: • Demographic information • Insurance information • A brief description of what they think they need • They will be offered: • A choice of providers to perform an assessment (based on number of providers available) • An appointment A person can also walk into a provider and request services as long as the provider are contracted within the MCO Network

23. In some counties there are other doors to Access Services… • There are DSS Continuums • A structured collaboration between DSS, Providers and the MCO regarding how adults & children enter care & receive services and address treatment barriers • Reclaiming Futures or Juvenile Justice Treatment Continuums • Another structure collaboration that provides a services for adjudicated youth and defines the relationships between DJJ, Providers and the MCO

24. What’s a reasonable Time frame to get an Assessment? • Emergent=Imminent risk for health & safety • 2 hours • Urgent • 48 hours • Routine • 14 calendar days

25. What are reasonable Expectations of comprehensive clinical assessment • Chronological general health & behavioral health history (MH & SA) of symptoms, treatment (tx), tx response & attitudes about tx over time, emphasizing factors that have contributed to or inhibited previous recovery efforts; • Biological, psychological, familial, social, developmental & environmental dimensions & identifies strengths, weaknesses, risks, & protective factors in each area; • Description of presenting problems, including source of distress, precipitating events, associated problems or symptoms, recent progressions, & current meds;

26. CCA’s Continued • Strengths, protective factors, & problem summary which addresses risk of harm, fxnal status, co-morbidity, recovery environment, & tx and recovery history; strengths-based assessment identifying consumer & family fxnal strengths including natural supports, preferences, needs, & cultural information specific to family; • Evidence of consumer & legally responsible person’s (if applicable) participation in the assessment; • Recommendation regarding target population eligibility (needed only for state-funded services);

27. And most importantly to you • Analysis & interpretation of the assessment information with an appropriate case formulation; and • Diagnoses on all five (5) axes of DSM-IV; & recommendations for additional assessments, services, support, or treatment based on the results of the CCA.

28. Comprehensive Clinical Assessment vs Psychological Evaluation • CCA-Performed by (at a minimum) a master’s level licensed clinician • Psychological Evaluation-Performed by a PhD, PsyD or LPA • Includes psychological testing • Higher rate (this is important to you re IPRS funds) • When would you want a Psychological Evaluation over a CCA? • After a CCA • If there is a question on differential diagnosis (ex. IQ, evidence of neurological damage and fxnl outcomes, or presence of underlying thought dx or personality disorder)

29. The Assessment & the Plan • The more information a provider has the better the assessment and the better the plan • Releases of information & communication is key to creating a valid assessment & successful plan • Not all therapists have a history with a forensic population • A person’s plan should include relevant or necessary supports • A person’s plan should include should be created around strengths as well as legal requirements

30. What’s a reasonable expectation on Authorization Turn Around? • For Medicaid services: • Expedited Request: 3 calendar days • Behavioral Health needs have created imminent risk for the health & safety of the consumer • Routine Request: 14 calendar days

31. What Kinds of Services & Treatment Support Children & Families “in the System”? • A little about Best Practices & Promising Practices • Adjudicated Youth Examples • MST • Functional Family Therapy • DSS & DJJ • Trauma Focused CBT • DSS • Nurturing Families (Parenting Class) • Parent Child Interactive Therapy (for little kids) • Intensive In Home

32. Residential Continued • Residential treatment is part of a treatment continuum however consider this quote: “…residential treatment is not an evidence-based practice, meaning that there is not sufficient research evidence to show that it is an effective form of treatment. According to the U.S. Surgeon General’s Report (1999), “In the past, admission to residential treatment was justified on the basis of community protection, child protection and benefits of residential treatment. However, none of these justifications have stood up to research scrutiny. In particular, youth who display seriously violent and aggressive behavior do not appear to improve in such settings, according to limited evidence” (p. 170). Hoagwood, Burns, Kiser, Ringeisen, & Schoenwald (2001) wrote that residential treatment centers and group homes are “widely used but empirically unjustified services” (p. 1185). “ Cited from: Magellan Health Services White Paper 2008

33. Residential Placement • What’s with the levels? • Level I: LowModerate structured supervised environment in a family setting • Level II: ModerateHighly structured supervised family or program type environment; • Level III: Highly structured supervised environment; awake during sleep time • Level IV: Physically secure locked environment; awake during sleep time • PRTF (Psychiatric Residential Tx Facility): ;awake during sleep time

34. Level I-Here’s what you might see • Frequent conflict, rule breaking • Frequent verbal aggression or infrequent, moderate physical aggression against property or people or self • Problems in school or vocational setting like: • Imminent risk or failure • Frequent behavioral problems • Difficulty maintaining appropriate conduct in community • Consistent difficulty accepting age appropriate & supervision

35. Level II • Severe conflict in home setting • Severe limited acceptance of behavioral expectations or rules • Impaired ability to form trusting relationships with caretakers • Frequent & severely disruptive verbal aggression &/or frequent & moderate property damage &/or occasional, moderate aggression towards self or others • Failure in school or vocational setting; Disruptive • On meds but need other tx interventions to control symptoms • Limits in ability to appropriately access supports, manage personal health, welfare or safety without intense support & supervision • IF at risk or has sexually inappropriate behavior-risk for offending low to moderate, creates community risk or is at risk for being victimized. (SOSE must be completed).

36. Level III • Frequent & severe conflict & refusal to follow rules • Pervasive or severe inability to form trusting relationships with caretakers • Frequent physical aggression including severe property damage or moderate to severe physical aggression towards self or others • School/vocational failure or major disruption • On medication but needs more intervention • Significant limitations in access appropriate services and not managing personal health, welfare & safety w/o intense support & supervision • If inappropriate sexual behavior: • Parent/caregiver unable to provide necessary supervision • Moderate to high risk of reoffending and victimizing others • Community risk • SOSE

37. Level IV • Severe conflict in family setting • Frequent & severe limitations in accepting rules • Severe inability to form trusting relationships with caretakers • Frequent physical aggression including severe property damage or moderate to severe aggression against self/others • Failure in school or vocational setting • Disruptive in community setting • Needs more intervention than medication • If inappropriate sexual behavior: • Parent/caregiver unable to provide appropriate supervision • Moderate to high risk for reoffending or sexually victimizing others • Community risk • SOSE

38. PRTF • Requires a Certification of Need (CON) completed by an independent medical team. • Must meet ALL of the following: • Diagnosis which requires & can reasonably be expected to respond to therapeutic intervention • Experiencing emotional or behavioral problems in home, community or tx setting & is not sufficiently stable to be treated outside of 24-hr therapeutic setting • Demonstrates capacity to respond favorably to rehabilitative counseling… • Hx of multiple hospitalizations or other tx episodes &/or recent inpatient stay with hx of poor tx adherence or outcome • Less restrictive levels of tx have been tried & were unsuccessful • Family situation & fxning levels are such that child cannot remain in home environment & receive community based treatment

39. A Little More about Adult Services Substance Abuse & Mental Health Needs • Individual, Family & Group Therapy • Substance Abuse Intensive Outpatient • Participation in Intensive In Home, Multisystemic Therapy, etc. Important but not in benefit plan • Offender Services • Parenting Classes Community Strategies for Development….

40. Who do I call if I get stuck? • Start with the LME or LME-MCO’s toll free # preferably during regular business hours but call lines are available 24/7 • If you are aware of poor services or other concerns, you can request the complaint line • If a provider is not in the network, they should call the provider information line • For very acute cases, you may want to connect with the Care Coordination team

41. Questions?