Tom C. Rawlings Director, Office of the Child Advocate State of Georgia (478) 757-2661

1. “Beyond Here Be Monsters”Navigating the Unfamiliar Waters of Georgia’s Changes in Mental Health AVLFDecember 10, 2007 Tom C. Rawlings Director, Office of the Child Advocate State of Georgia (478) 757-2661

3. First Stop: Georgia Crisis & Access Line • Run by Behavioral Health Link • 24/7 SPOE • Can provide referral to core provider or to crisis intervention services.

4. Care Management Organization Low-income Medicaid Right from the Start Medicaid Peachcare for Kids MHDDAD Parental Custody w/ no insurance, exhausted insurance, or otherwise ineligible for CMO or FFS Medicaid Where does the child fit? • Fee-for-Service Medicaid • Foster Care • SSI • Waivers • Adoption Assistance Medicaid THE MEDICAID ELIGIBILITY MANUAL IS AVAILABLE AT : http://www.odis.dhr.state.ga.us/3000_fam/3480_medicaid/MAN3480.doc

5. Care Management Organizations These Are Direct Contracts between DCH and the Health Plan. MHDDAD is NOT really involved. Capitated fee schedule Low-income Medicaid, Right from the Start Medicaid, Peachcare for Kids How do I get one? Normally assigned (888) 423-6765 (GA-ENROLL) 7am-7pm MF; 8:30am-12pm Sat. www.georgia-families.com FAQs at: http://dch.georgia.gov/00/channel_title/0,2094,31446711_43369236,00.html Where does the child fit?

6. Peach State Health Plan CBH run by Cenpatico Full contact information in your handouts Provider manual at: http://www.cenpaticoga.com/provider/manual Care Management Orgs

7. Wellcare of Georgia www.georgia.wellcare.com Default Plan? CBH administered by Magellan Clinical guidelines for behavioral health, including medical necessity guidelines: http://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/MNC.asp Provider manual: https://www.magellanprovider.com/MHS/MGL/about/handbooks/provider_handbook.pdf Customer Service: 800 231-1821. But it’s only available to consumers 7am-7pm M-F! Care Management Orgs

8. Amerigroup 800-660-4441, 24/7 “If you’re planning to hurt yourself or someone else, press 9.” Provider Manual https://www1.amerigroupcorp.com/providers/_documents/ga/ga_provider_manual.pdf Care Management Orgs

10. Care Management Organizations • Contracts with DCH • The Contractor shall at a minimum provide Medically Necessary services and Benefits as outlined below, and pursuant to the Georgia State Medicaid Plan, and the Georgia Medicaid Policies and Procedures Manual. Such Medically Necessary services shall be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to recipients under Fee-for-Service Medicaid. The Contractor may not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the diagnosis, type of illness or Condition.

11. Care Management Organizations • Contracts with DCH • In the event a Member requires Medicaid-covered services ordered by a State or federal court, the Contractor shall fully comply with all court orders while maintaining appropriate Utilization Management practices.

12. Fee-For-Service Medicaid • Foster Care, SSI, Waivers • A Partnership of Sorts Between MHDDAD and APS. • www.apsero.com • APS provides for these children the sort of external review that CMOs provide, except that APS doesn’t “have a dog in the fight.” • Obtain a core provider (there are over 100) through GCAL

13. MHDDAD $$$ • Parental Custody w/ no insurance, exhausted insurance, or otherwise ineligible for CMO or FFS Medicaid • Access a core provider through GCAL

14. What’s Available in the Community? • Supposedly, every service that’s available through Medicaid should be available through FFS, CMOS, or MHDDAD care. • Take a look at the Medicaid Provider Manuals: • www.ghp.georgia.gov, under “Provider Information” • APS Special criteria: • Intensive Family Intervention • http://www.apsero.com/Downloads/LOC%20Orientation%20-%20Jan%2019%202007.pdf • Community Support-Individual • http://www.apsero.com/Downloads/CSI%20for%20LOC%20Providers.pdf • If CMOs aren’t following APS criteria, ask them, “why not”

15. Medical Necessity • Early and Periodic Screening, Diagnosis, and Treatment Provisions of Medicaid Law (EPSDT), 42 USC 1396d • States must provide to persons under 21 “such other necessary health care, diagnostic services, treatment, and other measures . . . to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.”

16. Medical Necessity under EPSDT • “While there is no federal definition of preventive medical necessity, federal amount, duration and scope rules require that coverage limits must be sufficient to ensure that the purpose of a benefit can be reasonably achieved.... Since the purpose of EPSDT is to prevent the onset of worsening of disability and illness and children, the standard of coverage is necessarily broad... the standard of medical necessity used by a state must be one that ensures a sufficient level of coverage to not merely treat an already-existing illness or injury but also, to prevent the development or worsening of conditions, illnesses, and disabilities." • Rosenbaum and Sonosky

17. Medical Necessity • “Necessary” = medically necessary • Generally defined as a decision by a health care professional/provider that a person’s condition requires a service/course of treatment to address or improve a condition • From Alison Barkoff, Staff Attorney, Bazelon Center for Mental Health Law

18. “Correct” means to resolve a health problem or condition. “Ameliorate” means to lessen the burdens of the problem. What does “correct or ameliorate” mean when a problem is found during a screening? • From Alison Barkoff, Staff Attorney, Bazelon Center for Mental Health Law

19. Medical Necessity under CMOs • Contract with DCH: • Based upon generally accepted medical practices in light of Conditions at the time of treatment, Medically Necessary services are those that are: • Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Member’s medical Condition; • Compatible with the standards of acceptable medical practice in the community; • Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms; • Not provided solely for the convenience of the Member or the convenience of the Health Care Provider or hospital; and • Not primarily custodial care unless custodial care is a covered service or benefit under the Members evidence of coverage. • There must be no other effective and more conservative or substantially less costly treatment, service and setting available.

20. Medically Necessary? • “EPSDT cannot be simply relinquished to the MCOs, as the State remains ultimately bound by the EPSDT regulations.” • John B. v. Menke, 176 F. Supp. 2d 786, 801 (D. Tenn. 2001)

21. Reasonably Effective? • States also must ensure that the EPSDT services provided are reasonably effective. Thus, the State Medicaid Manual states at several points that EPSDT services must be sufficient "to achieve their purpose." • Katie A. v. Los Angeles County, 481 F.3d 1150, 1159 (9th Cir. 2007)

22. Sample EPSDT Letter (thanks to Josh Norris, www.thegao.org) RE: [Name of child] DOB: Dear _____________, I have assessed the above-named child. I am a [physician, nurse, psychologist, clinical social worker, occupational therapist, etc.] licensed to practice in the State of Georgia. I have determined based upon my training and experience that this child requires [list the treatments, procedures, therapies or tests you believe the child needs based upon your assessment]. I am making this request pursuant to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provisions of the Medicaid Act, 42 U.S.C.A. § 1396d(r). [Describe the child’s medical history, and current diagnoses and treatments. Describe the treatment that you are requesting/prescribing and a description of how this treatment will “correct or ameliorate” any physical or mental illness or condition of the child.] If you deny this request, please provide prompt written notice to this office [and the child’s parent or legal guardian] of the reason for the denial and the process by which your decision may be appealed. Sincerely,

23. I Need Residential Care! • CMO process • DFCS process • Parental Custody non-CMO process

24. “Unbundling” • Under the old Level of Care System, DFCS or MATCH or whomever would purchase a bundle of residential therapeutic services from a provider. • Now, the Medicaid officials require that the placement and the therapy be paid separately. • Essentially, what now happens is that: • The “Custodian” pays for Room, Board, and Watchful Oversight; and • The “Therapist” provides what is essentially outpatient therapy in a residential setting

25. “Unbundling” • Look at the RBWO “descriptions” • https://www.kidstarga.com/forms/docs/RBWOChartProviderRequirementsandChildCharacteristics.pdf • These descriptions have to be aligned with appropriate therapy, as determined by CMOs, or APS, etc. • What happens if there’s a disagreement?

26. DCH tells DHR that CMS Is requiring unbundling DHR tells residential Provider how to Implement unbundling APS disagrees with DFCS DFCS second-guesses APS APS Healthcare Determines Needed Therapy Residential Provider Takes child DFCS/DJJ Determine level Of RBWO DFCS second-guesses ORS ORS licenses Residential provider Core Provider determines child needs care

28. Residential Care: DFCS/DJJ Custody • Case manager works with core provider to determine child’s residential care needs. • In consultation with DFCS Provider Relations Unit, case manager selects a facility to provide room, board, and watchful oversight: • Watchful Oversight • Maximum Watchful Oversight • Core provider and residential facility work with APS to determine behavioral health needs.

29. Residential Care: Parental Custody • Family and Core Provider work with MHDDAD and APS to obtain RBWO and behavioral health services. • These should be coordinated through a local multidisciplinary team, but word on the street says these aren’t functioning as well as they did under Level of Care

30. Region One MHDDAD OFFICE 1305 Redmond Circle, Bldg 401 Rome, Georgia 30165 Nora Hall (706) 802 – 5272 nohall@dhr.state.ga.us Vicki Harrison (706) 802 – 5272 vmharrison@dhr.state.ga.us Region Two MHDDAD Office 3405 Mike Padgett Hwy, Bldg 3 Augusta, Georgia 30906 Kimberly Dempsey (706) 792 – 7663 kadempse@dhr.state.ga.us Felita “Michelle” Broadwater (706) 792 – 7662 fmbroadw@dhr.state.ga.us Region Three MHDDAD Office 100 Crescent Centre Parkway, Suite 900 Tucker, Georgia 30084 Shelia Kirksey (770) 414 – 3052 sdkirksey@dhr.state.ga.us Kelly Waterman (770) 414 – 3052 kwaterman@dhr.state.ga.us Region Four MHDDAD Office P.O. Box 1378 Thomasville, Georgia 31799-1378 Jacquelyn Ezell (229) 225 – 5099 jxezell@dhr.state.ga.us Georgia Brown (229) 225 – 5099 gepbrown@dhr.state.ga.us MHDDAD Regional C & A Program Specialists

31. MHDDAD Regional C & A Program Specialists • Region Five MHDDAD Office 1915 Eisenhower Drive, Bldg. 2 Savannah, Georgia 31406 Laura Ryan (912) 303 – 1670 laryan@dhr.state.ga.us

32. Residential Care: CMO Process • Have to request authorization through provider. • Magellan Example: • Parents contact Magellan. • Magellan requests records from current mental health provider – takes 14 days. • Have a treatment team meeting involving core provider, school officials, etc. • Then it’s determined at that point that child needs level of care, and find that facility that’s closest.

33. Residential Care: CMO Process • That’s all fine and dandy, but who pays RBWO when you’ve got a CMO kid without other State involvement?

34. CMO: In or Out? • CMO contracts exclude: • Children with severe emotional disturbance whose care is coordinated under the Multi-Agency Team for Children (MATCH) program; • Children less than nineteen (19) years of age who are receiving foster care or other adoption assistance under Title IV-E of the Social Security Act; • Children less than nineteen (19) years of age who are in foster care or other out-of-home placement;

35. CMO: In or Out? • Unanswered Questions: • What happens when a child goes from his home, where he has CMO Medicaid, to foster care? • For example, what if a child is in an institution for 30 days? • What happens when he goes from a residential DFCS or “MATCH” placement back into the community where he’d be in a CMO?

36. Residential Care Overview • Take a look at this Powerpoint by Roslyn Williams: • http://www.apsero.com/webx?293@953.kR91abfUd2w.0@.ee7df76

37. Individuals with Disabilities Education Act (IDEA) • Source of school-supplied Behavioral Health Services, including positive behavioral interventions required by IDEA 2004. • May be a source of residential treatment in limited circumstances. • May be able to use school-determined MH needs as a basis for obtaining Medicaid-paid care. • Good general resource: “Teaming Up: Using IDEA and Medicaid. . . . “

38. IDEA & CMOs • For Members up to and including age three (3), the Contractor shall be responsible for Medically Necessary IDEA services provided pursuant to an Individualized Family Service Plan (IFSP) or Individualized Service Plan(IEP). • For Members age four (4) and older, the Contractor shall not be responsible for Medically Necessary IDEA services provided pursuant to an IEP or IFSP. Such services shall remain in FFS Medicaid.

39. Getting into a PRTF • PRTFs are the old “level 6” facilities, now classified as “psychiatric residential treatment facilities,” for the most ill children. • Coastal Harbor • Devereux Georgia Treatment Network • Hillside • Inner Harbour • Laurel Heights • Macon Behavioral Health.

40. PRTFs • When DFCS’ Treatment Services Unit did most placements, children often stayed in PRTFs for years. • No incentive to move them; • No place for them to go. • With APS and now CMOs doing external review, these will be very short-term placements.

41. Processes for PRTFs • For DFCS and non-CMO parental custody children, similar process as with residential placement. • See Handouts • Good overview Powerpoint by APS folks: • http://www.apsero.com/webx?293@953.kR91abfUd2w.3@.ee7e689

42. CMO Processes for PRTFs • Good Question! • According to one CMO exec., they’re still figuring it out. • Apparently, the DCH contract did not specify any procedures for CMOs’ use of PRTFs. That was added as of July 1 for new entries, September 1 for existing clients. • At GRN, they’ve had 10 approvals from APS for PRTFs since 7/1/07; ZERO from CMOs.

43. Waivers • New Options Waiver Program • Comprehensive Supports Waiver Program • MR/DD • Katie Beckett Waiver • Waives the income limits so parents of children with serious disabilities can get Medicaid. • http://www.parenttoparentofga.org/roadmap/insurance/insurancedeeming.htmc • Manual: http://dch.georgia.gov/vgn/images/portal/cit_1210/26/56/46098632Katie_Beckett_Manual.pdf

45. Ongoing Questions • What are we going to do about children who are caught in the middle, because of: • Changes in status – Medicaid CMO/FFS/Private Insurance, Parental/State Custody • Turf wars between the various agencies and companies who might have responsibility

46. Ongoing Questions 2. Is there anything we can do to standardize the process, so that kids who are on a CMO are ensured of receiving the same consideration and standard of care as one with private insurance or one on fee-for-service Medicaid?

47. Ongoing Questions • What will be the relationship now between the CMOs and: • The Courts • The Interagency Teams and Systems of Care • The Schools

48. Must-See Resources • www.kidstarga.com • DFCS’ “Out of Home Care” website, which has lots of good, technical information on RBWO, specialized foster care, etc. • www.apsero.com • APS’ website has dozens of Powerpoints, pdfs, and other documents discussing every aspect of Georgia’s behavioral health care system. Most of the training that providers receive, and the criteria and processes used to access care, are posted here in some form. There are also AUDITS of various providers.

49. Must-See Resources • www.ghp.georgia.gov • The official website for Georgia Medicaid providers, with provider manuals for every service imaginable. • www.georgia-families.com • The website for the Georgia Medicaid CMO program, with enrollment information and access to all three CMOs.

50. Must-See Resources • www.gachildadvocate.org • The website of Georgia’s Office of the Child Advocate. We’ll keep updated information on Georgia’s children’s behavioral healthcare system going forward.