HealthChoices Behavioral Health Contract Changes by kei14036


									    HealthChoices Behavioral Health
    Contract Changes

                           Children in Substitute
                           Care (CISC) Placed
                            Out of Zone (OOZ)

1              9/15/2009
    Department of Public Welfare
          of Mental Health Public Welfare
    OfficeDepartment of and Substance Abuse                                                                              HealthChoices Behavioral Health
          Office of
    October 23, 2006 Mental Health and Substance   Abuse Services                                                                   Statewide Expansion
                                                                                                                                            Draft 3/9/06
                                       HEALTHCHOICES BEHAVIORAL HEALTH ZONES

                     45,650                                                                                              Susquehanna
                                             Warren             McKean            Potter   Tioga           Bradford         CCBHO
                                             4,954              6,895             2,715    5,209            9,325           5,576
             Crawford                        CCBHO              CCBHO             CCBHO    CCBHO           CCBHO                           Wayne
               VBH                                                                                                                         6,080
              13,711                                                                                                                       CCBHO
                                             Forest                                                                    Wyoming
                                              635              Elk       Cameron                                       CCBHO       Lackawanna
                            Venango          CCBHO            3,989        857                              Sullivan   3,637       CCBHO
             Mercer           VBH                             CCBHO         CCBHO           Lycoming          709                  27,644     Pike
              VBH           8,911                                                            CBHNP            CCBHO                           CCBHO
             18,388                                                  Clinton                 15,136    Luzerne                                4,888
                               Clarion                                CBHNP                            CCBHO
                                5,443 Jefferson                       5,315                            43,462
                               CCBHO     7,146                                                Columbia                 Monroe
            Lawrence                    CCBHO                                                 7,101                    CCBHO
             VBH                                Clearfield                         Union   Montour                     18,537
            14,377   Butler                       13,392         Centre            3,396    1,924             Carbon
                      VBH      Armstrong        CCBHO            9,319             CCBHO        CCBHO         CCBHO
                     14,594     VBH                              CCBHO                   Northumberland        6,574
                                                                               Snyder    11,160                        Northampton
            Beaver             9,887                                           3,531
                                       Indiana                                           CCBHO    Schuylkill            MBH
                                               Cambria                           CCBHO            17,407
            23,146                      VBH                                                                     Lehigh 26,451
                                       9,792      VBH               Mifflin Juniata               CCBHO           MBH
                   Allegheny                   19,882                6,744 2,199                                  46,198
                    CCBHO                             Blair           CCBHO            Dauphin            Berks           Bucks
                   150,640                            CBHNP                  Perry     CBHNP              CCBHO             MBH
                             Westmoreland             20,681                 CBHNP    33,195 Lebanon      53,075          34,259
                                 VBH                         Huntingdon      4,054            CBHNP                Montgomery
            Washington         38,452                         6,112                           12,975                  MBH
              VBH                                            CCBHO          Cumberland                                41,318
             24,223                                                          CBHNP               Lancaster
                                                                            12,687               CBHNP       Chester
                                       Somerset    Bedford                                       45,373      CCBHO            Philadelphia
                          Fayette       CBHNP       CBHNP          Franklin                                  23,673             CBH
              Greene       VBH         9,156       6,275   Fulton CBHNP      Adams       York                       Delaware 411,226
               VBH        29,793                           CBHNP   11,712    CCBHO       CCBHO                        MBH
              7,555                                        1,709             6,962       39,242                     59,416

                  SOUTHWEST                               LEHIGH/CAPITAL                   SOUTHEAST
                  Implemented Jan. 1999                   Implemented Oct. 2001            Implemented Feb. 1997       * Covered lives as of July 2007

                  NORTHEAST                              NORTH/CENTRAL STATE OPTION        NORTH/CENTRAL COUNTY OPTION
                  Implemented July 1, 2006               BH Implementation Jan. 1, 2007    BH Implementation July 1, 2007

2                                                                        9/15/2009
    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

3                     9/15/2009
    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

4                     9/15/2009
    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-

5                       9/15/2009
    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

6                     9/15/2009
    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

7                     9/15/2009
    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

8                     9/15/2009
    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
       Provider enrolls in BH-MCO’s network or is
        authorized as out-of-network provider

9                      9/15/2009
     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

10                       9/15/2009
     Key Considerations

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

11                      9/15/2009
     Which issues do not change?

        Children in Detention Centers more than 35
         –   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.

12                          9/15/2009

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