HealthChoices Behavioral Health Contract Changes

1. HealthChoices Behavioral Health Contract Changes Children in Substitute Care (CISC) Placed Out of Zone (OOZ)

3. Prior to August 1, 2009…D&A OOZ • Youth offended - appeared before the Judge • Judge ordered placement in a D&A residential non-hospital program • Court ordered where youth is placed • Youth remained until order was satisfied • Juvenile Justice system paid • No coordination of care with BH-MCO

4. After August 1, 2009…D&A OOZ • Youth Offends and goes before the Judge • Judge orders drug and alcohol assessment • ASAM Criteria affirms need for D&A non-hospital residential rehab • BH-MCO contacted and reviews for medical necessity – placement options offered at network provider or requested provider is approved

5. After August 1st contd. - • BH-MCO Care Managers conduct periodic review of ongoing medical necessity • Youth remains in treatment until criteria is no longer met or until court orders release • BH-MCO pays while medically necessary • C&Y can pay if no longer med necessay • After-care is coordinated through the BH-MCO

6. What is Potentially Different ? • Drug and alcohol assessment completed prior to placement • BH-MCO is contacted prior to placement • Youth is placed in a D&A treatment bed • BH-MCO pays for the treatment episode – can include room & board • BH-MCO arranges for after-care upon return home

7. Key Considerations • Inserting the BH-MCO in the process • Interface with New BH-MCOs • Use of the ASAM Criteria • Need to have youth in licensed D&A treatment beds • Providers may need to enroll in PROMISE • Rates are set by the BH-MCOs

8. Prior to August 1st – CISC OOZ • Dependent child is placed out of their HealthChoices Zone • Child remains or reverts to MA – FFS • Accesses BH services directly • TSS and RTF prior authorized through OMHSAS Medical Assistance Prior Auth Unit • BH-MCO not responsible for coordination of care

9. After August 1st – CISC OOZ • Dependent child is placed outside of zone • Child remains in, or is enrolled in, the BH-MCO of original residence • BH-MCO to be contacted for review of medical necessity (Appendix T)/auth of service • Provider enrolls in BH-MCO’s network or is authorized as out-of-network provider

10. What is Potentially different? • Service authorization must be requested of BH-MCO of child’s residence • BH-MCOs may have different policies, procedures and rates • All apply Medical Necessity Criteria found in Appendix T • BH-MCOs pay for services authorized • Care is coordinated by BH-MCO upon child’s return

11. Key Considerations • Additional services may be available in HC • Physical Health coverage is not impacted • HealthChoices rates are often higher than FFS • Providers must be enrolled in MA and credentialed to be in BH-MCO networks

12. Which issues do not change? • Children in Detention Centers more than 35 days • Children in detention centers more than 35 days will continue as FFS. Authorizations requested while the child is in detention will be conducted by OMHSAS UR. • If the child is placed before an authorization is requested, the BHMCO will need to review for medical necessity before payment can be made.