FLMH
"C. Attach the
plan's proposed written protocol describing its appointment system.
The protocol should address the following: ...
(2) Describe
the plan's proposed protocol for handling voluntary walk-in enrollees,
including methods of triage and typical waiting time to see a direct service
mental health care provider.
(3) If
a walk-in enrollee is not seen by his or her usual direct service mental
health care provider describe how information about this visit will be
transmitted to the enrollee's usual direct service mental health care provider?"
Florida Mental Health RFP, page 99.
HI
"31.000 Behavioral
Health Managed Care (BHMC) Plan...
Adult members
who have been initially determined by the health plan and confirmed
by DHS to have a serious mental illness (SMI) and children/youth who have
been determined and confirmed by DHS to be seriously emotionally disturbed
(SED) shall be enrolled in the behavioral health managed care (BHMC) plan...
31.100 Plan
Referral for an Evaluation
Upon determination
that a QUEST recipient is potentially SMI or SED, the health plan shall
refer the recipient for an evaluation to confirm the initial diagnosis...
The cost of completing the forms and obtaining additional documentation is the responsibility of the health plan. If the recipient needs to be interviewed, and requires transportation to the evaluation site, the cost shall be borne by the referring health plan...
The evaluation results and the enrollment date into the BHMC plan, if appropriate, will be provided to the member's health plan and the BHMC plan. The health plan has the right to appeal any denial of SMI/SED determination...
31.200 Enrollment
into BHMC Plan
Once a member
has been confirmed to meet the criteria of the BHMC plan, the member will
be enrolled in the plan...
Until enrollment into the BHMC plan is complete, the health plan retains responsibility for providing the behavioral health services. The health plan shall not receive any additional compensation for maintaining the care coordination/case management functions as these services are expected to be included in the capitation rate...
31.300 Behavioral
Health Managed Care Plan Implementation
On July 1,
1997 , existing SMI and SED QUEST recipients shall be identified and enrolled
in the behavioral health managed care plan. The DHS, DOH and the
behavioral health managed care plans will coordinate the transfer process
allowing sufficient lead time to ensure a smooth transition…" Hawaii
RFP, pages 28-30.
"33.300
Department of Health (DOH) Services...
Alcohol and
Drug Abuse Division (SDAD)...
The health
plan member may obtain a 'slot' by contacting the treatment program directly
and upon determination by the ADAD provider (and availability of a slot),
the member may be admitted. The ADAD provider will inform the plan of the
admission and expected-length of stay. Another way to obtain a 'slot'
would be for the plan to refer the member to a substance abuse residential
treatment provider and arrange for the utilization of an ADAD 'slot.'...
While the recipient is in an ADAD 'slot' the health plan remains responsible for all medical costs. The ADAD provider shall coordinate with the health plan for the patient's discharge from the residential treatment program. The health plan remains responsible for placing the member into other appropriate substance abuse treatment programs following discharge from the residential treatment program…" Hawaii RFP, pages 39-40.
"Adult Mental
Health Division (AMHD)...
The health
plans are encouraged to include the AMHD CMHCs in their provider networks.
The AMHD will contract for its CMHCs with the health plans to make the
CMHCs part of the plan's provider network. No individual CMHC will contract
independently with any health plan. The provider agreement shall not bind
the plan to use any of the CMHCs on a preferential basis or to use all
of the CMHCs...
Child and Adolescent
Mental Health Division (CAMHD)...
The health
plans are encouraged to include the CAMHD centers in their provider networks.
The CAMHD will contract for its centers with the health plans to make the
centers part of the plan's provider network. No individual center will
contract independently with any health plan. The provider agreement shall
not bind the plan to use any of the center on a preferential basis or to
use all of the centers…" Hawaii RFP, pages 35, 37-40.
IABH
"IV.
Mental health Services...
C.
Service Coordination and treatment Planning (Proposal Section)
Upon request,
MBC of Iowa can provide consultation to Iowa Plan providers. Through
the MBC of Iowa physician review network (available 24 hours a day), psychiatrists
who are Board Certified in Child and Adolescent Psychiatry, psychiatrists
with specialties in eating disorders, bipolar disorders, etc are available
for case consultation…" Iowa Behavioral Health Contract, page 58.
MD
"10.09.64.10...
.10 Special
Needs Populations.
An MCO applicant
shall include in its application the following information or descriptions:
...
C. Written
evidence, including treatment protocols, of the applicant's ability to
provide the range of clinical and support services specified in COMAR 10.09.65.05-.11,
to ensure appropriate and coordinated services to the following special
populations: ...
(7) Individuals
in need of substance abuse treatment…" Maryland COMAR 10.09.64.10.
"10.09.65.11-1
.11-1
Substance Abuse Identification and Treatment--TCA Recipients--Notification
Requirements...
B. An
MCO shall notify, or ensure that the enrollee's PCP notifies, the enrollee's
local department of social services when either of the following occurs:
(1) After
June 30, 1998, an enrollee fails to appear, within 90 days of enrollment,
for an initial appointment scheduled by the enrollee's MCO as required
by COMAR 10.09.66.07...
C. An
MCO shall notify, or ensure that the enrollee's PCP notifies, the enrollee's
local department of social services when either of the following occurs:
(1) The
result of the enrollee's substance abuse screen described in Regulation
.11D of this chapter is positive; or
(2) Any
follow-up diagnostic testing or treatment performed by the MCO or any MCO
provider reveals a substance abuse problem.
D. Notification.
When PCP is Responsible for Direct Referral for Substance Abuse Treatment...
(2) In
the circumstances described in §D(1) of this regulation, the MCO shall
notify, or ensure that the enrollee's PCP notifies, the enrollee's local
department of social services when any of the following occurs:
(a) The
enrollee fails to appear for or fails to complete a comprehensive substance
abuse assessment and placement appraisal...
(b) The
comprehensive substance abuse assessment indicates that the enrollee is
not in need of treatment; or
(c) The
PCP refers the enrollee for appropriate substance abuse treatment.
E. Treatment
Referral Notification by Comprehensive Assessment and Placement Appraisal
Provider...
(2) The
MCO shall notify, or ensure that the enrollee's PCP notifies, the enrollee's
local department of social services when the PCP refers the enrollee for
a comprehensive substance abuse assessment and placement appraisal...
F. The
substance abuse treatment provider to whom an enrollee is referred shall
provide notice to an enrollee's local department of social services office
when the enrollee:
(1) Has
been referred for appropriate substance abuse treatment;
(2) Fails
to schedule and appear for an initial appointment for substance abuse treatment:
…
(3) Is
awaiting the availability of appropriate treatment;
(4) Is
enrolled in a treatment program;
(5) Is
not actively enrolled in a substance abuse treatment program; or
(6) Has
successfully completed the treatment...
.11-2
Substance Abuse Identification and Treatment-TCA Recipients-Notifications,
Consent Forms, and Liaison...
(3) If
the enrollee's medical records document a positive substance abuse screen
or any follow-up diagnostic testing or treatment has revealed a substance
abuse probability:
(a) The
PCP shall initiate notification of the enrollee's local department of social
services office of any of the events listed in Regulation .11-1B-D of this
chapter; and
(b) If
the enrollee is currently receiving substance abuse treatment, the PCP
shall transmit to the enrollee's substance abuse treatment provider at
least one copy of the carbonized consent form received from the enrollee's
local department of social services office, authorizing the release of
confidential alcohol or drug treatment information and signed by the enrollee."
Maryland COMAR 10.09.65.11-1, .11-2
MA
"Section 2.12
Behavioral Health Program Services...
K. BH
Program Linkage to PCP
The Contractor
shall implement within the first six months of the Contract a plan to facilitate
communication and coordination of Enrollee mental health, substance abuse,
and medical care between the BH Program Provider, and the Enrollee's PCP.
The plan shall, at a minimum, include policies and procedures that meet
the following requirements: ...
2. Require the BH Program Provider to request written consent from the Enrollee to release information regarding mental health or substance abuse services, or both, to the Enrollee's PCP...
3. Ensure that the BH Program Provider communicates and coordinates the Enrollee's care with the PCP once written consent has been obtained to release information…" Massachusetts Contract, pages 68-87.
MABH
"3.2 Delivery
and Coordination of Services
The Contractor
shall: ...
J. manage certain
inpatient mental health beds for uninsured children that DMH currently
manages pursuant to a Memorandum of Understanding between DMH and those
private psychiatric hospitals ('Private Psychiatric Hospitals') identified
in Appendix Y to this Contract. Management shall include referral and screening
of clinically appropriate, uninsured children, utilization review services
and discharge planning. Services provided by the Private Psychiatric Hospitals
pursuant to the current MOU, a copy of which is also attached hereto in
Appendix Y to this Contract, and any subsequent MOU that DMH may negotiate,
shall be provided free of charge to the Contractor, DMH and the Division.
The Contractor shall separately report to the Division on inpatient admissions
of uninsured children to the Private Psychiatric Hospitals…" Massachusetts
MH/SAP Contract, Appendix A, pages 21-22.
"2.02.09 Require that inpatient hospital Providers develop organizational and clinical linkages with each of the DEPs and/or ESPs, including procedures to credential and grant admitting privileges to DEP and/or ESP psychiatrists and hold regular meetings and conduct ad hoc communication on clinical and administrative issues with the DEPs and/or ESPs." Massachusetts MH/SAP Contract, Appendix B, page 12.
"5.08
Primary Care Clinician (PCC) Linkage
The Contractor
shall:
5.08.01
Submit to the Division for prior review and approval and implement within
the first six months of the Contract a plan to facilitate communication
and coordination of Recipients' mental health, substance abuse, and medical
care between the Provider, PCC, and the Contractor. The plan shall,
at a minimum, include policies and procedures that meet the following requirements:
...
c. ensure
that the Provider communicates and coordinates the Recipient's care with
the PCC once written consent has been obtained to release information;
d. in
coordination with the division's PCC Plan staff or their designees, provide
education and training for all PCCs to familiarize the PCCs with the use
of mental health and substance abuse screening tools, instruments, and
procedures to identify mental health and substance abuse problems at the
earliest point in time;
e. provide
education to Providers about the PCC Plan.
f. designate
the Contractor's appropriate clinical and non-clinical staff who shall
participate in division sponsored PCC training;
g. require
the contractor's medical director or assistant medical director to attend
the PCC advisory committee meetings on a regular basis;
h. identify
and designate the Contractor's representative who shall function as a liaison
with the PCC Plan;
i. coordinate
its ICM Program with the division's PCC Plan high cost case management
program, which shall involve the exchange of information and collaborative
placement and discharge Planning coordination for cases with coexisting
medical and mental health/substance abuse diagnoses; and
j. create
a policy and procedure to be followed by the contractor and, at the division's
discretion, the division's drug utilization review program, to monitor
the prescription patterns of the contractor's physicians, and, at the division's
discretion, PCC Plan physicians' prescription patterns..." Massachusetts
MH/SAP Contract, Appendix B, pages 45-46.
"5.1.1C.5:
PERFORMANCE INCENTIVES AND PENALTIES INITIATIVES...
c. Incentives
Only
1) Primary
Care Clinician Linkage
The Contractor
shall measure the percentage of disabled adult members admissions to inpatient
psychiatric facilities where there is evidence of telephonic or written
notification by the inpatient facility to the member's Primary Care Clinician,
as identified by the member or DMA; provided, however, that such measure
shall include only those admissions of disabled adult members who have
provided written consent to their treating facility to contact their PCC..."
Massachusetts MH/SAP Contract, Amendment 1, pages 14, 16.
MO
"The DMH service coordinator and the MC+ health plan…primary care provider must collaborate on behalf of the client to insure coordinated care, access to care, and to avoid duplication of services…" Missouri RFP, page 66.
NEBH
"11.11 MH/SA
Providers: The following provisions describe the MH/SA provider's responsibilities
in the NHC: ...
11.11.3
MH/SA Provider Qualifications and Responsibilities: Pursuant to the PHP’s
contractual responsibilities, the PHP shall ensure that the MH/SA provider
complies with the following: ...
(b) Signing
a contract with the PHP as a MH/SA provider which explains the provider’s
responsibilities and compliance with the following NHC requirements: ...
(2) Providing services within the MH/SA Package per 471 NAC to all
clients according to the Enrollment Report and complying with all requirements
for referral management and prior authorization in the most appropriate
and least restrictive level of care, as defined in this RFP;
(3) Coordinating appropriate referrals to MH/SA services, and when
necessary with medical/surgical services;
(4) As appropriate, working cooperatively with specialists, consultative
services and other facilitated care situations for special needs clients,
e.g., deaf and hard of hearing, persons with dual-diagnosis, etc.;
(5) Ensuring or providing continuous access to MH/SA services and
necessary referrals of urgent or emergent nature available 24-hour, 7 days
per week, access by telephone to a live voice… or an answering machine
that shall immediately page an on-call MH/SA professional so referrals
can be made for non-emergency services or so information can be given about
accessing services or procedures for handling medical problems during non-office
hours;
(6) Not refusing an enrollment or otherwise discriminate against
a client solely on the basis of age, sex, race, physical or mental handicap,
national origin, type of illness or condition, except when that illness
or condition can be better treated by another provider type;
(7) Ensuring compliance with the Americans With Disabilities Act
(ADA)...
(8) Continuing to be responsible for the client until another provider
is located and treatment can be transferred...
(12) Maintaining a communication network providing necessary information
to the client's primary care physician and/or medical/surgical plan as
frequently as necessary based on the client’s needs.
Note: … A focused effort to coordinate the provision, authorization, payment and continuity of care is a priority for MH/SA providers participating in the NHC. The PHP shall monitor overall coordination between these two service areas, i.e., medical/surgical and MH/SA. The PHP shall ensure the MH/SA provider is knowledgeable about the Basic Benefits Package and other similar services and ensure that appropriate referrals are made to meet the needs of the client;
(13) Communicating with agencies including, but not limited to, local public
health agencies, community-based MH/SA agencies, etc.;
(14) Providing information to the Department as required, including
the HHS Protection and Safety worker and others involved with the care
coordination of services, for a child who is a ward of the Department;
(15) Informing clients about all treatment options, regardless of
cost or whether such services are covered by the Nebraska Medical
Assistance Program; and
(c) Providing accurate information to the PHP in a timely manner as requested so that information can be exchanged with the Department." Nebraska Behavioral Health Contract, pages 54-56.
NV
"b. Mental
Health Services
If a parent/guardian,
Contractor PCP or Contractor Case Manager suspects a child between the
ages of birth to 18 presents an emotional/behavioral problem, the Contractor
shall ensure the child is assessed for mental health services. Refer
to NAC 433.040 for the definition of Serious Emotional Disturbance (SED).
The Contractor is responsible to assure completion of the initial diagnostic or SED assessment, for a child age birth to 18, regardless of the referral source (e.g. parent or guardian, primary care physician, etc.)
Upon determination of SED, or reversal of SED determination, the DCFS or contracted provider must notify DHCFP. DHCFP will send written notice to the parent or guardian regarding the child's right to disenroll or remain voluntarily enrolled with the Contractor. If an SED determination is reversed, the participant will be required to mandatorily enroll with a Contractor. If the SED determined child remains voluntarily enrolled, the Contractor is required to provide all medically necessary mental health services.
If the participant elects disenrollment, the DHCFP disenrollment process will be followed, and the Contractor will made an appropriate referral to the Division of Child and Family Services (DCFS). The Contractor is responsible for transferring the appropriate participant records/information to DCFS. DHCFP may review participant records, including SED assessments, as indicated." Nevada Contract, page 24.
NM
"2.A.5
Referral and Coordination
The CONTRACTOR
shall have and comply with written policies and procedures for the coordination
of care and the arrangement, tracking, and documentation of all referrals
including referrals to the following providers: behavioral health providers...
The CONTRACTOR's policies and procedures shall ensure that referrals including
referrals to the following providers: behavioral health providers...for
medically necessary services are available to members...
2.A.5.a
Coordination of Physical and Behavioral Service Benefits
Physical health
and behavioral health services must be provided through an integrated.
clinically coordinated managed care system. Both behavioral and physical
health care providers need access to relevant medical records of mutually
served members to insure maximization of the benefit of services to the
member...
2.A.5.a.ii Ongoing Reporting, While the member is receiving services from a behavioral health provider, the behavioral health provider must keep the member's PCP informed of drug therapy; laboratory and radiology results; sentinel events such as hospitalization. emergencies, incarceration, discharge from a psychiatric hospital or from behavioral health services: and transitions in level of care. The PCP shall keep the behavioral health provider informed of drug therapy; laboratory and radiology results: medical consultations: and sentinel events such as hospitalization and emergencies...
2.A.5.a.v The CONTRACTOR shall have and comply with policies and procedures governing referrals from behavior health providers for physical health consultation and treatment." New Mexico Contract, pages 15-16.
OR
"S.
Cooperation with Mental Health Organizations (MHOS)
Contractors
shall cooperate with MHOs as follows:
(1) Consult and communicate with the OMAP Member's mental health providers as Medically Appropriate and within the laws governing confidentiality as specified in OAR 410-141-0180, Prepaid Health Plan Recordkeeping, Oregon Health Plan Administrative Rules.
(2) Develop and implement methods of coordinating with MHOs in order to assure access and appropriate coordination of services delivered to mutual OMAP Members, particularly OMAP Members with exceptional service needs. Such coordination shall be within laws governing confidentiality." Oregon Contract, page 15.
ORMH
"b. Preventive
and Early Intervention Services...
(b) Contractor
shall adopt program with the participation of Health Care Professionals,
OMAP Members, Family Members, and Local and/or Regional Allied Agencies."
Oregon Mental Health Contract, page 13.
"f. Chemical
Dependency Providers
Contractor
shall coordinate with Chemical Dependency Providers as Medically Appropriate
and within laws governing confidentiality and shall provide technical assistance
to help assure that OMAP Members with dual diagnosis are identified and
referred to treatment. Contractor shall work with FCHPs and Chemical Dependency
Providers certified by the Office of Alcohol and Drug Abuse Programs (OADAP)
to develop the capacity to provide Appropriate services to dually diagnosed
OMAP Members so the needs of such persons can be better met." Oregon
Mental Health Contract, page 18.
"DEFINITIONS
With the following
exceptions and additions, the terms in this agreement have the same definitions
as those terms appearing in Oregon Administrative Rules(OARs)...
Community Coordinating
Committee: A committee composed of representatives from the Local
Community Mental Health Program, State Office for Services to Children
and Families, Juvenile Court, local educational district, and Oregon State
Hospital, Children and Adolescent Treatment (CATS) program. The Committee
performs the intake functions to assure the child's need for Long Term
Psychiatric Care at the CATS Program...
Community Mental Health Program (CMHP): The organization of all services for persons with mental or emotional disorders and developmental disabilities operated by, or contractually affiliated with, a LMHA, operated in a specific geographic area of the state under an intergovernmental agreement or direct contract with Division." Oregon Mental Health Contract, Appendix K, pages K1, K4.
PABH
"b. Coordination
(Part IV, Section D.2)
1)
Describe how the managed care program will coordinate services for covered
populations with county administered mental health and drug and alcohol
services...
9) Describe the procedures used to coordinate with the state mental hospital and county mental health authority, as applicable, in the development and implementation of admission and discharge planning to ensure appropriateness and continuity of treatment." Pennsylvania Behavioral Health RFP, page 22.
RI
"2.08.04.03
Transitioning Between Non-Network And Network Providers
The State recognizes
that members may need to, at times, transition between non-network and
network providers to continue to receive needed substance abuse services.
This can occur when members first enroll in a Health plan, when members
change Health Plans, or at other times. Contractor agrees to have
written policies and procedures for transitioning members between non-network
and network providers to assure continuity of care, including paying for
one or more transition visits with a non-network provider." Rhode
Island RFP, page 36.
TN
"2-3.
Benefit/Service Requirements and Limitations…
c. Specialized
Services...
3.
Mental Health/Substance Abuse Services...
The
CONTRACTOR shall assure active coordination between primary health care
and mental health/substance abuse care, including case management and continuity
of care services…" Tennessee Contract, pages 7-16.