OMHSAS HealthChoices Behavioral

Health Program

PCCYFS Children’s Services Policy Day

October 19, 2010

OMHSAS Vision Statement

Every person with serious mental illness and/or addictive disease, and every child and adolescent who abuses substances and/or has a serious emotional disturbance will have the opportunity for growth, recovery and inclusion in their community, have access to services and supports of their choice, and enjoy a quality of life that includes family and friends.

2

HealthChoices Oversight Secretary

OMHSAS Deputy SecretaryOMAP

HealthChoices Steering Committee

OperationsChildren’s

BureauPolicy

Quality Improvement&

Medical Director

Fiscal

MIS

Executive Committee

Joint Management

3

HC-BH Program Overview

Statewide Mandatory MA Managed Care Begin in 1996- implemented statewide in 2007 1915(b) CMS Waiver of Social Security Act

Available in 67 Pennsylvania Counties 2.1 million Medical Assistance eligible members Annual cost $2.8 billion 2010 Goals:

Improve Access to Care Improve Quality of Care Stabilize MA Spending

4

HC-BH Program Structure

BH HealthChoices Separate Contract County Right of First Opportunity to bid on contract 34 total BH contracts – 32 with County Government DPW holds direct contract with BH-MCO for Greene County & 23

County North Central area OMHSAS Regional Field Office Contract Monitoring Team

BH –PH Coordination Meetings HealthChoices PH Contracts ACCESSPlus PH Contracts PH Voluntary Contracts

5

6

Department of Public Welfare HealthChoices Behavioral Health Office of Mental Health and Substance Abuse Services Statewide Expansion Draft 3/9/06

Cambria VBH 21,515

Huntingdon 6,519 CCBHO

Blair CBHNP 21,983

Forest 656 CCBHO Venango

VBH 9,186

Mercer VBH 19,875

Lawrence VBH 15,305 Butler

VBH 16,576

Clarion 5,780 CCBHO

Crawford VBH 15,308

Erie VBH

52,063 Warren

5,322 CCBHO

Jefferson 7,781 CCBHO

Clearfield 14,265 CCBHO

Centre 10,002 CCBHO

McKean 7,408 CCBHO

Elk 4,402 CCBHO

Cameron 985 CCBHO

Potter 2,793 CCBHO

Northampton MBH 31,636

Lebanon CBHNP 15,647

Cumberland CBHNP 16,449

Perry CBHNP 4,523

Juniata 2,679

Mifflin 7,608 CCBHO Dauphin

CBHNP 37,631

Schuylkill 20,654 CCBHO

Montgomery MBH 58,478

Berks CCBHO 61,473

Bucks MBH 44,761

Lehigh MBH 50,561

Columbia 7,842

Montour 2,133 CCBHO

Snyder 4,187 CCBHO

Union 3,865 CCBHO

Northumberland 12,963 CCBHO

Lycoming CBHNP 16,888

Tioga 5,475 CCBHO

Sullivan 710 CCBHO

Bradford 9,457 CCBHO

Pike CCBHO 5,986

Carbon CCBHO 7,681

Luzerne CCBHO 50,587

Monroe CCBHO 22,615

Susquehanna CCBHO 5,688

Wyoming CCBHO 4,021

Wayne 6,620 CCBHO

HEALTHCHOICES BEHAVIORAL HEALTH ZONES

SOUTHWEST Implemented Jan. 1999

LEHIGH/ CAPITAL SOUTHEAST Implemented Feb. 1997 Implemented Oct. 2001

BH Implementation July 1, 2007 January 1, 2007

NORTH/ CENTRAL RIGHT OF FIRST OPPORTUNITY

BH Implementation NORTHEAST BH Implementation July 1, 2006

Lackawanna CCBHO 32,114

Adams CCBHO 8,355

York CCBHO 46,905

Lancaster CBHNP 56,734

Chester CCBHO 30,226

Philadelphia CBH 447,415

* Covered lives as of July 2010

Allegheny CCBHO 166,394

Beaver 24,735

Armstrong VBH 10,674

Indiana VBH 10,885

Westmoreland VBH 43,545

Washington VBH 25,302

Greene VBH 7,493

Fayette VBH 30,697

Bedford CBHNP 6,912

Clinton CBHNP 5,827

Franklin CBHNP 15,168

Fulton CBHNP 2,130

Somerset CBHNP 9,636

Department of Public Welfare Office of Mental Health and Substance Abuse July 22, 2010

Delaware MBH 68,349

SOUTHWEST Implemented Jan. 1999

NORTHEAST Implemented July 1, 2006

LEHIGH/ CAPITAL Implemented Oct. 2001

NORTH/ CENTRAL STATE OPTION BH Implementation Jan. 1, 2007

SOUTHEAST Implemented Feb. 1997

NORTH/ CENTRAL COUNTY OPTION BH Implementation July 1, 2007

Contractual Requirements

Programmatic:

Access to Services

Ongoing Review of Required Services

Complaints and Grievance Processes

7

Contractual Requirements

Development of Services

Who decides to add a services?

When is the decision made?

Who pays for the new services?

What about room and board?

Provider Network & Credentialing 8

Contractual Requirements

Financial Claims Payment

Timely filing of Claims Clean Claims

Primary Contractor Shall adjudicate: 90% Clean Claims within 30 days 100% Clean Claims within 45 days 100% of all claims within 90 days

Timeliness for Reimbursement Third Party Liability

9

Eligibility Requirements

Are there still different zones? Who is responsible for out-of-state placements? Who is responsible for checking eligibility? What happens when there is dropped eligibility? HIP/FFS Eligibility in Juvenile Detention Centers

10

Timelines Standards For Authorization and Payment of Services

State Standards/Bulletins

OMHSAS- 10-04-Psychological/Psychiatric/Clinical Re-Evaluations and Re-Authorizations for BHRS

OMAP- 01-93-04- Payment for MH services Provided in a RTF for Eligible Individuals Under 21 Years of Age

OMAP- 1165-95-01- JCAHO Accredited Services

11

Medical Necessity Criteria

Evaluation and documentation-Physician (Psychiatrist) or Licensed Psychologist

Severity of the illness present meets criteria for specific level of care/service.

Potential for person to benefit from this level of care. Most appropriate and least restrictive to meet MH needs. Continued Care Criteria- person continues to meet

criteria and benefit from service. Discharge/Referral Criteria

12

Access to Service

The provider network must provide face-to-face treatment intervention within: One hour for emergencies Twenty-four hours for Urgent situations Seven days for routine appointments and for specialty

referrals. Upon initial face-to-face intervention, the

implementation of the treatment services must adhere to the prescribed treatment plan, including the start date and frequency of treatment services.

13

Evidence Based Practices

MST, FFT, MTFC, PCIT Researched Based Over 75% Counties at least one EBP What do we need to know?

Must meet MA Requirements

Must maintain fidelity/certification to model

14

Questions

&

Discussion

15

Contact Information

Julie Barley- Acting Director for Eastern Operations- jbarley@state.pa.us

Valerie Vicari- Director for Western Operations- vavicari@state.pa.us

Stan Mrozowski- Director, Children’s Bureau- smrozowski@state.pa.us

Scott Talley- Chief of Operations & Service Delivery, Children’s Bureau- stalley@state.pa.us

16