FLMH | HI | HIBH | IABH | MA | MABH | MN | MO | NE | NEBH | OR | PABH | SC | UTMH
"2.6 Services
Not Covered...
The contractor
shall not be responsible for... substance abuse treatment or medical/surgical
interventions associated with a psychiatric problem. If the contractor
determines the need for these or other services, the contractor shall refer
the enrollee to the appropriate service provider..." Florida Mental
Health RFP, pages 30-31.
"Co-morbidity:
Patients with
a substance abuse diagnosis must also meet the diagnostic criteria for
an above accepted mental illness.
Patients with DD/MR in addition to an allowable diagnosis will have to be at worst in the mild range (317.00) for eligibility" Hawaii RFP, Appendix L, page 3.
"Substance abuse treatment (dual diagnosis) - specialized outpatient assessment and treatment for the special problems encountered by persons who are seriously mentally ill (SMI) or severely emotionally disturbed (SED) and who abuse/use substances. Services include, but are not limited to, education, counseling, psychotherapy; for the individual, group and family. Services are provided largely by staff of the Master's level or above with training in dual diagnosis." Hawaii Behavioral Health RFP, page A10
"41.0
COVERED DIAGNOSES...
The Contractor
will be responsible for providing services necessary in the behavioral
care and treatment of the covered diagnoses for Iowa Plan enrollees who
are dually diagnosed wit a covered diagnosis and non-covered diagnosis."
Iowa Behavioral Health Contract, pages 26- 27.
"II. Integrated
Mental Health and Substance Abuse (Proposal Section 7A2.3)
The following
is a clarification of the meaning of 'fully integrated':
It is the intent of MBC of Iowa to fully integrate mental health and substance abuse services for Iowa Plan eligible persons when the person is dually diagnosed. The vision of the Iowa Plan is to improve treatment planning by ensuring that the needs of dually diagnosed eligible persons are met either through simultaneous treatment or separate but continuous treatment. At the same time, confidentiality rules must be abided by for both mental health and substance abuse." Iowa Behavioral Health Contract, page 55.
"Required Services
for Mental Health Conditions
Required services
also must be made available by the Contractor. Although not covered
in the Iowa fee-for-service Medicaid program, these services also are appropriate
ways to address the needs of the people with mental health diagnoses...
* Concurrent
services for those diagnosed with both chronic substance abuse and chronic
mental illness...
Other Required
Mental Health Services...
* Dual Diagnosis
Treatment Program: The Contractor shall work with the recommendations
of the DHS/DPH task force to develop at least one program by January
2000 which would serve those both Medicaid and non-Medicaid Iowa Plan enrollees
with dual diagnoses . The Contractor shall work with the Departments
in the development of training and certification for counselors trained
in working with both substance abuse and mental health needs of those served
through the Iowa Plan. This will include the development of guidelines
to assess the need for dual diagnosis treatment to serve as the basis for
the authorization and reimbursement of dual diagnosis services…"
Iowa Behavioral Health Contract, pages 81-82.
"Section 2.12
Behavioral Health Program Services...
J. BH
Dual Diagnosis
The Contractor
shall: ...
1. Develop
a list of a continuum of services to meet the needs of Enrollees with a
BH Program BH Dual Diagnosis. The Contractor shall:
a. Ensure
that the continuum of care shall include adequate service capacity for
the following:
1) assessment;
2) BH
Emergency Services;
3) BH
Inpatient Services;
4) Level
III Freestanding Detoxification;
5) Partial
Hospitalization for Adults, Children and Adolescents or alternative step-down;
6) Residential
Substance Abuse Treatment;
7) Structured
Outpatient Addiction Program;
8) Psychiatric
Day Treatment;
9) BH
Outpatient Services; and
10) Acupuncture
Detoxification…" Massachusetts Contract, pages 68-86.
"5.01 Department
Structure and Staffing
The Contractor
shall:
5.01.01 Develop
a Utilization Management Department that shall be operational on the Full
Service Start Date and shall be responsible for the following: ...
h. specialty
services and programs, such as:
1. Dual
Diagnoses…" Massachusetts MH/SAP Contract, Appendix B, page 29.
"5.07 Dual Diagnosis
The Contractor
shall:
5.07.01
Design, develop, and submit to the Division for prior review and approval
a list of a continuum of services to meet the needs of Enrollees with a
Dual Diagnosis. The Contractor shall:
a. ensure
that the continuum of care shall include adequate service capacity for
the following:
1.
assessment;
2.
Emergency and Crisis Stabilization;
3.
Inpatient Services;
4.
Freestanding Detoxification;
5.
Partial Hospitalization or alternative step-down;
6.
Residential Treatment;
7 .
Structured Outpatient Addiction Program;
8.
Day Treatment;
9.
Outpatient Services; and
10.
Acupuncture Detoxification...
b. consult and collaborate with DPH/BSAS in building the continuum of care, developing education programs for clinicians, and developing Credentialing and recredentialing requirements for substance abuse clinicians.
c. in conjunction with the Division, work with designated central office staff from DMH and DPH/BSAS to encourage the development of appropriate residential programming at a range of intensities and types which meet the needs of enrollees with a Dual diagnosis upon their discharge from inpatient levels of care, and which complement Outpatient Services." Massachusetts MH/SAP Contract, Appendix B pages 44-45.
"1. DMA
Covered Services
A. Inpatient
Services - shall mean twenty-four hour services which provide medical intervention
for mental health or substance abuse diagnoses, or both.
1. Enhanced Level III Detoxification for Pregnant Women - shall mean short term medical treatment for substance use withdrawal, medical assessment and intervention, including both medical and social components, to ensure quality substance abuse treatment and obstetrical care to pregnant women
2. Inpatient Mental Health Services - shall mean hospital services to stabilize an acute psychiatric condition which: 1) has a relatively sudden onset; 2) has a short, severe course; 3) poses a significant danger to self or other; and/or 4) has resulted in marked psychosocial dysfunction and/or grave mental disability.
3. Inpatient Substance Abuse Services (Level IV) - shall mean hospital services which provide a planned detoxification regimen of 24 hour medically directed evaluation, care and treatment for psychoactive substance abusing individuals in a medically managed inpatient setting.
4. Level III Detoxification - shall mean Inpatient Substance Abuse Services that provide short-term medical treatment for substance use withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post- detoxification referrals. These services may be provided in licensed freestanding or hospital-based programs." Massachusetts MH/SAP Contract, Appendix C, page 1.
"5.1.1C.5:
PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES...
c. Incentives
Only...
4) Intensive
Case Management/Consumers who are Dually- Diagnosed
The Contractor
shall target an increase in enrollment in the Intensive Case Management
(ICM) program of at least 100 individuals, at least 75 of whom must be
members with a dual- diagnosis (substance abuse and psychiatric) and include
both disabled adults and adolescents. All dually diagnosed individuals
must be newly enrolled in the ICM subsequent to June 30, 1997..."
Massachusetts MH/SAP Contract, Amendment 1, pages 14, 16-17.
"Section 5 of
Appendix A of the Contract is amended by inserting the following new Section
5.1.3.G…
Section 5.1.3.G.:
Performance Incentives, Penalties, and Initiatives: Provision and Standards...
4. Dual diagnosis/Dual
Recovery - through the efforts of a statewide coalition of consumers and
advocated, including the Massachusetts Clubhouse Coalition, the Contractor
shall coordinate and ensure the provision of dual diagnosis (mental illness
and substance abuse) recovery education, training and support, Such
education, training and support. Such education, training and support
shall emphasize the Dual Recovery Anonymous model, with the goal of establishing
more groups in the Commonwealth, The compliance target for this standard
shall be:
1) demonstration
of engagement with a statewide coalition of consumers and advocates to
ensure the provision of dual diagnosis recovery education, training
and support; and
2) the convening
of a statewide conference on the Dual Recovery Anonymous model."
Massachusetts MH/SAP Contract, Amendment 6, pages 1, 3-4.
"Section 6.15. Serving Minority and Special Needs Populations. The HEALTH PLAN must offer appropriate services for the following special needs groups. Services must be available within the HEALTH PLAN or through contractual arrangements with providers to the extent that the service is a covered service pursuant to this Article...
Section 6.15.6. Dual MI/Developmentally Disabled (DD) or MI/CD clients: comprehensive assessment, diagnostic and treatment services provided by staff who are trained to work with clients with multiple disabilities and complex needs." Minnesota Contract, pages 66-67.
"cc. Mental
health and substance abuse services are included in the comprehensive benefit
package as follows: ...
* For
inpatients with dual diagnosis (physical and behavioral) identified at
admission or during the stay, the health plan will be financially responsible
for all inpatient hospital days necessary for the physical health problem.
These admissions are subject to the prior authorization and concurrent
review process identified by the health plan." Missouri RFP, page
50.
"2.11.9
Behavioral Services for Category of Aid 4 'Other Medicaid Children': ...
b. Inpatients
with dual diagnoses (physical and behavioral) identified at admission or
during the stay, the health plan will be financially responsible for all
patient hospital days necessary for the physical health problem…"
Missouri RFP, page 63.
"13.49 Mental Health/Substance Abuse (MH/SA) Coordination Issues: The following rules apply when coordination of services is required between the medical/surgical plan responsible for the Basic Benefits Package and the MH/SA plan responsible for the MH/SA services, as addressed by the Department in regulations governing both components of the NHC. In situations where the client isn’t participating in both components of the NHC, the associated service is coordinated with the Nebraska Medicaid Assistance Program on a fee-for-service basis.
13.49.1 Emergency Room Services for MH/SA Services: Emergency room services provided to a client who is participating in the MH/SA component of the NHC is the responsibility of the client’s medical/surgical plan regardless of the client’s final or principle diagnosis.
At the time a MH/SA provider initiates an evaluation and/or treatment for the client, the medical/surgical plan is no longer responsible for MH/SA related service. Authorization for MH/SA services from that point forward must be obtained from the MH/SA plan.
13.49.2
Admissions for 24-Hour Observation:
When a client
who is participating in the MH/SA component of the NHC is admitted to an
acute care (i.e., medical/surgical) facility as an outpatient for 24-hour
observation (for purposes of a MH/SA diagnosis), the MH/SA plan is responsible
for payment of the observation stay…" Nebraska Contract, pages 97-98.
"11.9 Dually
Diagnosed Clients: The PHP shall ensure that the MH/SA provider incorporates
the needs of the ‘dually diagnosed’ client and provides active treatment
or coordination of treatment for clients with concurrent or secondary complicating
problems. The ‘dually diagnosed’ clients may have problems such as
substance abuse, medical problems, developmental delays, or mental retardation.
11.9.1 Dual Diagnosis Treatment Defined: Dual diagnosis treatment
is the simultaneous and integrated treatment of coexisting disorders."
Nebraska Behavioral Health Contract, page 53.
"4. COVERED
SERVICES...
Covered Services
are those Medically Appropriate services specified in OAR 410-141-0480,
Oregon Health Plan Benefit Package of Covered Services, which shall include:
...
(3) For mental health condition/treatment pairs that appear on the funded portion of the list, Contractor is only responsible for Physician-Outpatient Somatic Mental Health services and Outpatient Hospital-Somatic Mental Health services except to the extent that Contractor may have a separate Agreement with the Mental Health and Developmental Disability Service Division…" Oregon Contract, pages 15-16.
"WORK STATEMENT
QUESTIONNAIRE...
a. In-Plan
Services (part IV, Section D.1)
1)
Describe strategies for delivering clinical services to priority populations,
particularly addressing persons with serious mental illness…as well as
special needs populations such as children and adolescents with mental
retardation and behavioral disorders eligible for behavioral health rehabilitation
services; person s with co-existing psychiatric and addictive disorders,
and elderly persons with behavioral health needs." Pennsylvania Behavioral
Health RFP, page 21.
"D. Tasks
1.
In-Plan Services...
a.
The MCO will provide timely access to diagnostic, assessment, referral,
and treatment services for members for the following benefits: ...
7) behavioral health rehabilitation services for children and adolescents (EPSDT) with psychiatric and substance abuse disorders…
13)
effective July 1, 1997, the following will be in-plan services: ...
d)
Behavioral health rehabilitation services (EPSDT) for children and adolescents
with mental retardation." Pennsylvania Behavioral Health RFP, pages
48-49.
"4.9.3 Targeted
Case Management Services
Targeted case
management services are defined as those services necessary to coordinate
an optimum lifestyle for a targeted patient population through a coordination
effort which monitors the patient's needs. Patients who are dually diagnosed
with complex social and medical problems may require targeted case management
services from more than one case management provider...
The Contractor shall be responsible for developing a system for coordinating health care for members that require case management services that avoids duplication and ensures that the members needs are adequately met…" South Carolina Contract, page 18.
"B. Clarification
of Covered Services...
4.
Inpatient and outpatient mental health services are Covered Services when
they are Medically Necessary for the treatment of mental illness for individuals
who carry a dual diagnosis of mental illness and developmental disorder/mental
retardation (regardless of IQ) or organic (neurologic) disorder or substance
abuse disorder." Utah Mental Health Contract, page 6.