Document Sample
					    Prepaid Mental Health Plan
  Community Stakeholder Meeting
       AHCA Areas 3 and 4

December 16, 2004 – Jacksonville, FL
   December 17, 2004 – Ocala, FL

• Deborah McNamara
  – Prepaid Mental Health Plan Coordinator
  – (850) 414-0633;
• Trecia Perry
  – Prepaid Mental Health Plan Contract Manager
  – (813) 871-7600 x133;
• Jorja Daniels
  – Prepaid Mental Health Plan Area Coordinator
  – (813) 871-7600 x132;
 Purpose of the Stakeholder
• Present an overview of the Prepaid
  Mental Health Plan
• Answer questions
• Elicit feedback and
           HB 1843 and
       Mental Health Services
• Prepaid Mental Health Plans will be
    implemented statewide by July 1, 2006.
•   Health Maintenance Organizations will
    provide community mental health services to
    their members statewide.
•   Children in the HomeSafeNet database will
    receive services through a specialty prepaid
    network beginning July 1, 2005.
        What Does This Mean?

•   One Prepaid Mental Health Plan in each AHCA area
    will provide mental health care for people enrolled in
    the MediPass program.
•   Members of Medicaid HMOs will be excluded from
    participating in the Prepaid Mental Health Plan.
•   Children in the HomeSafeNet database will be
    excluded from participating in the Prepaid Mental
    Health Plan. A new prepaid plan will be developed
    operated by the Community-Based Care
    Organizations beginning July 1, 2005.
       Planned Implementation
AHCA Area Request for        Prepaid Mental Health
          Proposal Release   Plan Implementation Start
          Date               Date
5, 7       December 2004     May 2005

2, 3, 4    February 2005     July 2005

11         June 2005         November 2005

8, 9, 10   October 2005      March 2006
      What is a Prepaid Mental
            Health Plan?
• A Prepaid Mental Health Plan is a managed
    care organization that contracts with AHCA to
    provide mental health services to its
    members though a capitated payment
•   AHCA pays a per member, per month
    (PMPM) fee to the plan based on the age and
    eligibility category of each member.
   Who will be our Prepaid
 Mental Health Plan provider?
The Prepaid Mental Health Plan contractor must:
   – Have experience in providing community mental
     health services.
   – Be licensed with the Department of Insurance
     under Chapter 624, 636, or 641.
   – Be accredited through an organization such as the
     Joint Commission on Accreditation of Health Care
     Organizations, the Commission on Accreditation
     of Rehabilitation Facilities, the National Committee
     for Quality Assurance, or the Utilization Review
     Accreditation Commission.
                RFP Process
•   A Request for Proposal is released by AHCA.
•   Interested parties submit a Notice of Intent to Submit
    a Proposal to AHCA.
•   AHCA will hold a Bidder’s Conference to give
    interested parties an opportunity to ask informal
    questions about the requirements.
•   All formal questions must be submitted to AHCA in
    writing. A written response will be prepared and will
    become an addendum to the RFP.
•   Interested parties submit proposals to AHCA.
•   No less than three reviewers will evaluate and score
    each proposal.
•   The entity whose proposal receives the highest score
    will be awarded the contract.
 Who is eligible to be in the
Prepaid Mental Health Plan?

Any Medicaid recipient who elects to enroll in
MediPass for the provision of their physical
health care services will be assigned to the
Prepaid Mental Health Plan for the provision
of their mental health services, unless they are
    Who is NOT eligible to be in the
     Prepaid Mental Health Plan?
•   Recipients who have both Medicaid and Medicare.
•   Persons living in an institutional setting, such as a nursing
    home, state mental health treatment facility, or prison.
•   Medicaid-eligible recipients receiving services through Hospice.
•   Recipients in the Medically Needy Program.
•   Newly enrolled recipients who have not yet chosen a health
•   SOBRA eligible pregnant women and presumptively eligible
    pregnant women.
•   Individuals with private major medical coverage.
•   Members of a Medicaid HMO.
•   Children enrolled in the HomeSafeNet database.
•   Recipients receiving FACT services.

       Quality Services
• Services must be:
• Services cannot be:
  –More restrictive than those offered in
    the fee-for-service plan
   Services Covered by the
  Prepaid Mental Health Plan
• Inpatient Psychiatric Hospital Services
   –45 days for adult recipients
   –365 days for children
• Outpatient Psychiatric Hospital Services
• Psychiatric Physician Services
• Community Mental Health Services
• Mental Health Targeted Case Management
    Community Mental Health Services

•   Individualized Treatment Plan Development and
•   Evaluation and Assessment Services
•   Medical and Psychiatric Services
•   Mental Health Counseling/Therapy
•   Psychosocial Rehabilitative Services
•   Clubhouse
•   Therapeutic Behavioral On-Site Services
•   Self-Help/Peer Services
•   Crisis Intervention Mental Health Services and Post-
    Stabilization Care Services
         Additional Service
• Monitoring of recipients in:
  –State Mental Health Treatment Facilities
  –Jails and Juvenile Detention Facilities
  –Residential Treatment Facilities
• Provision of services to residents in Assisted
  Living Facilities with a Limited Mental Health
            Optional Services
• The Prepaid Mental Health Plan provider has
    flexibility to offer additional services that it
    deems beneficial.
•   Optional Services listed as part of the bidder’s
    original proposal become mandatory services
    once the contract is executed.
•   Examples may include:
     –Respite Care
     –Support Groups
     –Prevention Services
         Services NOT Covered
•   Specialized Therapeutic Foster Care
•   Therapeutic Group Care Services
•   Behavioral Health Overlay Service (BHOS)
•   Statewide Inpatient Psychiatric Program (SIPP)
•   Residential treatment programs, long-term care
•   Transportation
•   Medical/Surgical Interventions
•   Medications
•   Florida Assertive Community Treatment Services (FACT)
•   Comprehensive Behavioral Health Assessments
•   Qualified Evaluator Services
•   Substance Abuse Services
     Downward Substitution of
• Prepaid Mental Health Plan providers may
    offer alternative services to their members.
•   Examples of downward substitutions include
    psychologists and social workers in private
•   Services provided as a downward substitution
    may not be more restrictive than the level of
    care available in the fee-for-service system.
         Access Requirements

•   Direct service providers must be available to every
    member within:
     – 30 minutes typical travel time in urban areas
     – 60 minutes typical travel time in rural areas
•   Appointment times:
     – Immediate access for emergencies
     – Within 23-hours for urgent appointments (e.g.,
       non-emergent allergic reactions to medication)
     – Within 7 days for routine appointments
           Staffing Standards

• Ratios of staff members to recipients for
    specific disciplines
•   Requirements for staff members trained in
    specific specialty areas (e.g., young children,
    domestic violence, etc.)
      Community Coordination

• The Prepaid Mental Health Plan provider
    must be an active participant in the mental
    health treatment community.
•   The plan is required to develop linkages to
    other vital community systems, such as the
    schools, the criminal justice system, and
    agencies serving the homeless.
      Medicaid Managed Care
         Advisory Group
• Each AHCA area will have a Medicaid
    Managed Care Advisory Group that meets
•   Members include the Prepaid Mental Health
    Plan contractor, Medicaid HMOs, the
    Department of Children and Families, mental
    health care providers, and local advocacy
•   Recipients of care are encouraged to become
    active participants.
Operational Issues

       Transition Plan for New
• The Prepaid Mental Health Plan is required to
    provide an transition plan for new enrollees.
•   For recipients who have been participating in
    treatment during the previous six months, the
    plan must continue to authorize services until
    the Individualized Treatment Plan is reviewed
    and a transition plan is developed.
Grievances and Fair Hearings

• The Prepaid Mental Health Plan is
    required to have a grievance and
    appeal system in place that is approved
    by AHCA.
•   Members may access the Department
    of Children and Families Medicaid Fair
    Hearing process.
        Quality Improvement

• The Prepaid Mental Health Plan
    contractor must have a quality
    improvement program.
•   The quality improvement program will
    be reviewed by AHCA and by the
    External Quality Review Organization.
•   The Prepaid Mental Health Plan contractor is required to submit
    reports to AHCA on a regular basis.
•   Examples of reports include:
     – The number of members assigned to each provider.
     – The results of annual member and stakeholder satisfaction
       surveys conducted by the plan.
     – Grievances and the actions taken by the plan to resolve the
     – Community outreach activities.
     – Service utilization.
     – Critical incidents.
     – Financial reports.

• Conducted jointly between AHCA and the
    Department of Children and Families.
•   A minimum of two on-site monitoring visits
•   Quarterly desk reviews.
•   Annual evaluations by the External Quality
    Review Organization.
      How can the community
         ensure success?
• Get to know your local AHCA staff.      Each
    Prepaid Plan will have AHCA staff members
    assigned to provide oversight and answer
•   Actively participate in your local Medicaid
    Managed Care Advisory Group.
          Further Information

• Area One Prepaid Mental Health Plan
  Request for Proposal:

• 1915b Waiver Information:
  Please Send Comments

Deborah McNamara, LCSW
Agency for Health Care Administration
2727 Mahan Drive, MS 20
Tallahassee, FL 32308

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