MULTNOMAH COUNTY OREGON

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					                               MULTNOMAH COUNTY OREGON
                 DEPARTMENT OF COUNTY HUMAN SERVICES. Mental Health And Addiction Services Division
                  421 SW Oak Street, Suite 520, Portland, Oregon 97204, Phone (503) 988-5464, Fax (503) 988-5870



        ADULT AND CHILD CRITERIA FOR INTEGRATED BEHAVIORAL
                   HEALTH SERVICES ACCESSING THE
                    MULTNOMAH TREATMENT FUND
                AND INDIGENT MEDICATION PROGRAM

Multnomah Treatment Fund is a safety net program for Multnomah County indigent citizens
who do not qualify for OHP (Medicaid) due to income restrictions. Multnomah Treatment
Fund may also be used as a funding source while individuals are waiting for or reinstating
OHP coverage.
PLEASE NOTE: These instructions apply to those qualifying MTF adults and children
being served in general or school-aged outpatient or adult SMI level services only.

Criteria for Initial Authorization
    1 Financial: income is at or below 200% of current federal poverty level
    2 Clinical:
           a. Client meets the Priority 1 clinical criteria* as outlined in ORS 430.675, which
                may include a diagnosis of severe mental health disorder (psychotic spectrum
                disorders, bipolar or severe major depressive disorders); and
           b. Client is high risk as evidenced by recent discharge from a psychiatric acute care
                facility or from incarceration, or if an adult, in jeopardy of losing custody of
                children, or if a child, in jeopardy of being removed from their home all due to
                severe mental illness.

Criteria for Re-authorization:
    1 Financial: income is at or below 200% of current federal poverty level
    2 Clinical:
           a. Client continues to meet a diagnosis of severe mental health disorder (psychotic
               spectrum disorders, bipolar or severe major depressive disorders; and
           b. Client is currently prescribed Clozaril or intramuscular medication for his/her
               psychiatric disorder; or
           c. Client has a HAP Shelter-Plus Voucher
           d. If client does not meet Priority 1 clinical criteria, provider has demonstrated
               attempts to locate non-MTF funded community-based treatment service and has
               not been successful and there is a strong possibility that the client will
               significantly decompensate without ongoing treatment services.

Additional Processes & Expectations:
  3 Every provider working with clients funded by MTF is required to assist clients in
      applying for insurance coverage and/or other resources as soon as possible. Please note,
      that clients who meet criteria for MTF qualify for the Indigent Medications program
      (please see below for more information).


   Page 1 of 3                                                                                                     July 2011
    4   For individuals who are Medicare beneficiaries, providers will be required to attempt to
        locate providers who accept Medicare and/or bill Medicare first.
    5   MTF will be approved only for co-pays and payment for services not covered by
        Medicare benefits.
    6   Mental Health Assessments and Treatment Plans do not need to be submitted when
        requesting MTF authorization/reauthorization. However, the Mental Health and
        Addiction Services Division (MHASD) expects this documentation to be completed and
        current for ongoing quality assurance.


*Priority 1 is defined as those persons who, in accordance with the assessment of professionals in the field of
mental health, are at immediate risk of hospitalization for the treatment of mental or emotional disorders, or
are in need of continuing services to avoid hospitalization, or pose a hazard to the health and safety of others.
***************************************************************************************************
Multnomah Treatment Fund:
Contracted mental health agency staff should complete the following steps in order to request
authorization for eligible consumers. The referenced form below can be located at the Verity
Provider webpage: http://web.multco.us/mhas/mental-health

STEP 1) Agency clinician screens first for financial then clinical criteria as outlined above.
STEP 2) Initial Authorization, Psychiatric Services or Re-authorization: agency will complete
         and submit a 1 page Adult/Child Authorization Request and Attestation Form.
STEP 3) FAX ADULT/CHILD AUTHORIZATION REQUEST AND ATTESTATION
          FORM#: (503)-988-3575. Multnomah County will initiate an authorization in
          CIM. Adults may be authorized up to 12 months, children up to 6 months. It is
          essential that this form is complete or it will be returned for completion of data
          elements before the authorization is approved.
****************************************************************************************************
Indigent Medication Program:
Verity Providers also have the ability to request up to a 60 day supply of psychiatric
medications for consumers who meet the above clinical and financial MTF criteria. It is not
required to have an outpatient authorization in place in order for providers to request Indigent
Medications.

Providers should complete the steps below in order to request medications for eligible
consumers. All referenced forms can be located at the Verity Provider webpage:
http://web.multco.us/mhas/mental-health


STEP 1) Agency's prescriber fills out the Indigent Client Pharmacy Log (IM) and faxes the IM
         Log and the Financial Verification Form to the Multnomah Call Center (MCC), at fax
         # (503)-988-3137.

STEP 2) Fax the IM Log to the applicable pharmacy listed below that Multnomah County
         contracts with for this program.

STEP 3) After verification of the consumer’s eligibility (financial and clinical criteria), the MCC
         will authorize up to 60 days of medication during a 6 month time period.

STEP 4) The pharmacy contacts MCC to verify eligibility. Pharmacy will then fill up to 30
         days of medication at a time. The consumer will then have refills available until 60
         days has been exhausted.
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Number in Family               Monthly Gross Income is less than:
1                              $1805
2                              $2428
3                              $3052
4                              $3675
5                              $4298
6                              $4922
7                              $5545
8                              $6168

STEP 5) During this 60 day period it is expected that the agency will make every attempt to
         obtain either outside prescription assistance or eligibility under the Oregon Health
         Plan for the authorized consumer. Some websites that might be helpful for
         prescription assistance programs are: www.phrma.org or www.needymeds.org.

Please note: the process for obtaining prescription assistance can take up to 2 months or more,
so it is necessary to get started on these applications as soon as you apply for the IM program.

In relation to any prescribed psychiatric medications through the IM program, reimbursements
for lab draws are also covered. Agencies will order and pay for labs they currently have
relationships with before requesting reimbursement from the County. To request
reimbursement, providers shall submit an invoice with proof of payment to the address below
within 90 days from date of service:
Multnomah County MHASD
Attn. Business Services
421 SW Oak St. Suite 520
Portland, OR 97204

MTF Financial Criteria: An individual is financially eligible for services funded by MTF if
his/her family income is below the following guidelines. These guidelines are based on 200%
of the 2009 Federal Poverty Level Guidelines.




Participating pharmacies for the Indigent Medication Program:
Brooklyn Pharmacy, Inc.                       Payless Drugs
Contact person: Mike                          Contact person: Monique
3131 SE Milwaukie                             PO Box 230969
Portland, OR 97202                            Portland, OR 97281
Phone: 503.234.3488                           Phone: 503.626.9436
Fax: 503.235.0373                             Fax: 503.372-1792
ID #93-0498369                                ID #94-3382598
Hi-School Pharmacy/PMC                        Gateway Medical Pharmacy
Contact person: Patrick Mann                  Contact person: Lynn Virtue
501 SW 10th Ave.                              1125 NE 99th Ave.
Portland, OR 97205                            Portland, OR 97220
Phone: 503.226.6644                           Phone: 503.254.7383
Fax: 503.226.2908                             Fax: 503.254.4568
ID #91-1504881                                ID #93-1244084




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