Other

AZ | AZBH | CA | DE | DC | FLMH | HI | HIBH | IL | IN | IABH | KY | MD
MA | MABH | MN | MO | NEBH | NV | NH | NJ | NM | NY | ND | OH | OR
ORMH | PA | PABH | RI | TN | TX | UTMH | WA | WV

“2. BEHAVIORAL HEALTH SERVICES...
Covered services include: ...
g. Behavior management (limited for Title XXI)
h. Psychosocial rehabilitation (limited for Title XXI)…” Arizona Contract, page 16.

AZBH

“1. SCOPE OF SERVICES...
Eligibility: ...
Covered services include: ...
b. Behavior Management
l. Laboratory and Radiology Services for Psychotropic Medication Regulation and Diagnosis
m. Psychosocial Rehabilitation...
Title XXI (KidsCare) Limitations: Title XXI covered services are subject to the following limitations for each contract year...
b. The following outpatient behavioral health services are limited to a total of 30 visits for each contract year: Behavior management… psychosocial rehabilitation...
f. The following outpatient services are to be provided as medically necessary with no annual service limitation: …laboratory and radiology services for psychotropic medication regulation and diagnosis.
g. Bed hold days… are not covered under Title XXI program.” Arizona Behavioral Health Contract, pages 10-11.

“16. OUTREACH
ADHS and its subcontracted RBHAs shall provide outreach activities designed to inform members of the availability of behavioral health services...

ADHS shall ensure that its subcontracted RBHAs and their providers actively participate in outreach activities to Title XIX and Title XXI members in high risk groups, including but not limited to the homeless, seriously mentally ill members, members with co-morbid medical and behavioral health disorders and substance abusing pregnant women.” Arizona Behavioral Health Contract, page 19.

“Behavior Management
Description of Service:
Behavior management services are therapeutic interactions, supervision and direction which may include observation to prevent a person from harming self or others, assistance with personal care and activities of daily living and other household services incidental to and consistent with the behavioral health needs of a member. These services may be provided by a behavioral health professional, a behavioral health technician or a behavioral health paraprofessional...

Psychosocial Rehabilitation
Description of Service:
Psychosocial rehabilitation is a comprehensive program of active behavioral health treatment services which may include activities of community and daily living, training in communication, and assistance with psychotropic medication, symptom management, assistance in utilization community resources, and other daily routines. Usually performed in a group but may be one-to-one if addressed in the treatment plan. Psychosocial rehabilitation services may be provided by a behavioral health professional, a behavioral health technician or a behavioral health paraprofessional.

Service Limitation: ...
2. Psychosocial rehabilitation services provided to Title XXI (KidsCare) members count toward the 30 outpatient visit limit. Two or more units of the same service provided on the same day will count as one unit.” Arizona Behavioral Health Contract, BHS Guide, pages 10-11.

“ARTICLE II - DEFINITIONS...
N2. Specialty Mental Health Service means:
1. Rehabilitative services, which includes mental health services, medication support services, day treatment intensive, day rehabilitation, crisis intervention, crisis stabilization, adult residential treatment services, crisis residential services, and psychiatric health facility services...
4. Psychiatrist services;
5. Psychologist services…” California Contract, pages 2, 14.

“6.5 Wrap-Around Services
Diamond State Health Plan, Medicaid members only, enrolled in the DHSSHP are also entitled to a number of services not included in the Basic Benefit Package. Services not covered under the managed care program include: ...
(d) Medically necessary behavioral health services in excess of prepaid plan limits listed in Appendix H.
(e) Day treatment by continuous treatment teams for mental illness or substance abuse
The services listed above are currently covered under the Delaware Medicaid program. For these wrap-around services, the State will continue to reimburse the billing provider directly. Although MCOs are not responsible for directly furnishing wrap-around services, they are responsible for coordinating the overall delivery of care with out-of-network providers whenever one of their patients requires wrap-around services. The major types of out-of-plan services with which MCOs must coordinate are described below…” Delaware RFP, page II.39.

“6.5.2 Behavioral Health Benefits
Behavioral health benefits for adults and children will be provided both within the Basic Benefit Package and, in the case where more extensive services are needed for Diamond State Health Plan, Medicaid members, by the appropriate State agencies. Both adults and children will receive a limited set of behavioral health benefits through their respective MCOs (see Appendix M). Those patients requiring more extensive treatment will then be referred to the appropriate State agency for continuing treatment.

6.5.2.1 Children’s Behavioral Health
The basic benefits package for children will include thirty (30) behavioral health outpatient units per year (where a unit of
service is defined as one (1) hour of care). These thirty (30) units may include any combination of counseling, substance abuse or other appropriate services. If a child appears to require further, more intensive services or has exhausted the benefits provided in the managed care health plan package, then the MCO will screen the child with a protocol provided by the Division of Child Mental Health Services (DCMHS). Should any disagreement arise concerning the referral, the dispute will be resolved by a committee that includes the MCO’s medical/clinical director and a cross-section of employees of various State departments. The State’s Department of Services for Children, Youth, and Their Family (DSCYF) will provide and/or coordinate all inpatient behavioral health services for children from birth to age eighteen (18).

Child Behavioral Health services for children from birth to age eighteen (18)who need behavioral health services in excess of the basic benefit package will receive services from the State’s DSCYF. Appendix N provides a layout of responsibilities between the MCOs and the DSCYF integrated benefit...
The MCO must have the capacity to provide for involuntary commitments for evaluation and treatment of individuals meeting the criteria, in accordance with Chapter 50, Title 16, Delaware Code and Chapter 22, Title 16, Delaware Code and for emergency detentions, in accordance with Chapter 51, Title 16, Delaware Code, and any other applicable provisions that are codified in the future.

For members involuntarily committed under Chapter 22 or 50, Title 16, the following applies:
(a) for members who are in an inpatient, the MCO will ensure that the treatment provider transports the individual to the commitment hearing. The treatment provider provides adequate staff to supervise the individual, and a psychiatrist (Chapter 50) or a licensed physician (Chapter 22), is present to provide relevant testimony at the commitment proceedings.
(b) For members who are inpatient and involuntarily committed under Chapter 50, the MCO ensures the provision of a 24 hour authorization and transfer process for those individuals who are initially taken to Delaware Psychiatric Center (DPC). Under this 24 hour process, the MCO will authorize the appropriate MCO provider to accept and treat the committed individual being transferred from DPC.
(c) For outpatient members the MCO ensures that the individual is aware of the time and place of the hearing, will provide any necessary assistance so that the member is able to be present and will insure that the required treatment personnel are present to provide testimony.
(d) If a member is discharged from an involuntary inpatient commitment, the MCO and the MCOs inpatient facility will coordinate with DADAMH and the inpatient facility to ensure continuity of treatment.

For members with an emergency detention under Chapter 51, Title 16, the following applies:
The MCO ensures the provision of a 24 hour authorization and transfer process for those individuals who are initially taken to Delaware Psychiatric Center (DPC). Under this 24 hour process, the MCO will authorize the appropriate MCO provider to accept and treat the detained individual being transferred from DPC.
For members court-ordered for treatment, the following applies:
(a) The MCO will be responsible for the provision of all behavioral health services within the basic health benefit for Medicaid eligible adults ordered by a court;
(b) The MCO will not unilaterally indicate that the court-ordered treatment does not meet medical necessity;
(c) The MCO will ensure that, in the appropriate drug court related cases, the MCO will work with the Treatment Access Center (TASC) and interface with case managers in providing treatment.

The Division of Alcoholism, Drug Abuse and Mental Health (DADAMH) may provide behavioral health benefits after the
benefits outlined in the benefits package have been maximized and if DADAMH determines that the member needs extended benefit services provided by that Division DADAMH will serve adults who are severely and persistently ill (SPI) (See Appendix O) because of mental illness, alcoholism, or drug addiction. MCOs that have adult enrollees who, based on the MCO’s initial screening, may meet the diagnostic, functioning, and service history/utilization criteria for severely and persistently ill, and thus need extending benefit services, can make referral to the Division of Alcoholism, Drug Abuse and Mental Health for an intensive screening/assessment, for possible transfer to DADAMH services. Individuals who do not meet DADAMH’s criteria will be referred back the to the MCO. Should any disagreement arise concerning the referral, the dispute will be resolved by medical and/or clinical directors or designees of the MCO, DADAMH and DSS.

The MCO will designate a clinical liaison with DADAMH to serve as a point of contact regarding issues of referral to the MCO from DADAMH and from the MCO to DADAMH. The MCO will make the referral to DADAMH using the referral/transfer form developed by DADAMH (Appendix P). DADAMH will review the completed member referral packet, in a timely manner, to determine eligibility for the extended behavioral health services benefit. DADAMH will in a timely manner give the MCO the decision, the name and phone number of the DADAMH intake agency and the name of a contact person (if applicable), if the member is approved, and the with appropriate reasons for denial, if the referral is denied.

The MCO ensures that all information needed to make a timely decision will be provided to DADAMH. The MCO recognized that insufficient information will delay DADAMH’s decision or result in a decision based on limited information.

For members who are accepted as SPI for extended benefit services, the MCO will notify the member of the decision immediately and give the member the name of the DADAMH intake agency, the contact person (if applicable) and phone number. The MCO will coordinate with DADAMH and the intake agency to ensure continuity of treatment.

For members receiving extended benefits services, DADAMH will interface with the MCO case manager, when DADAMH has determined, at any time in the annual benefit cycle, that the member is no longer in need of extended benefit services due to improvement in behavioral health status. DADAMH and the MCO will agree on a date the member can be referred back to the designated MCO for service provided under the Basic Benefit package. In such cases, DADAMH, after the members’ consent to release the information, will prepare a member discharge summary, which will include a summary of the members treatment plans, medications and any other pertinent information required to promote the least disruptive transfer for members. The MCO ensures that the member will be seen within 30 working days of the submission of the transfer to the MCO.

MCOs must attempt to treat and resolve behavioral health problems within the basic benefit package prior to making a referral to DADAMH for assessment…” Delaware RFP, pages II.40-II.46.

“6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a))

The following services marked with an ‘X’ are covered by the State Child Health Insurance Program as part of a basic MCO benefit package when medically necessary with exceptions/limitations noted: ...
6.2.10. ‘X’ Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) - inpatient mental health services may be provided as a ‘wrap-around’ service for up to 31 days per calendar year with the limitation that the 31 days also includes any other mental health and/or substance abuse treatment services (including outpatient, residential and any other treatment modality) outside of the basic MCO benefit of 30 outpatient visits. Children who need inpatient services beyond this will convert to Medicaid Long-Term Care.” Delaware RFP, Appendix A (SCHIP), page A.18.

“H. COVERAGE AND BENEFITS
4. Mental Illness and Addiction Disorder Treatment Services
a. Services needed to treat mental illness or addiction disorders other than pharmaceuticals are excluded from the provision and coverage requirement of this contract.
b. Provider is responsible for arranging for mental illness or addiction disorder services if such assistance is requested by the enrollee or by services in enrollees’ medical records.
c. Provider shall make available to the member a directory of mental health and substance abuse providers in the District. The District shall furnish a copy of the directory of the Provider. Provider shall assist the member in select a mental health and substance abuse provider and making an appointment, when requested and necessary.” District of Columbia Contract, pages 21, 25.

FLMH

“2.2 General Service Requirements
A. The prepaid mental health plan contractor will provide a full range of mental health care service categories authorized under the state Medicaid plan and the state mental health program plan, as follows.
3. Psychiatric physician services...” Florida Mental Health RFP, page 21.

“2.3 Medicaid Service Requirements...
C. Physician Services
Physician services are those services and procedures rendered by a licensed physician at a physician’s office, enrollee’s home, hospital, nursing home or elsewhere when dictated by the need for preventive, diagnostic, therapeutic or palliative care, or for the treatment of a particular injury, illness or disease as specified in the Medicaid Physician Provider Handbook.

Physician services policy requirements are as follows: ...
2. The contractor excludes provision of clinical unproven
procedures.
3. The contractor is not responsible for physician services
provided as a component of therapeutic foster care or children’ residential treatment (Levels I-IV). These services will continue to be provided by the HRS District Six Department of Alcohol, Drug Abuse and Mental Health.
D. Community Mental Health Services
Community Mental Health Services are rehabilitative services which are psychiatric in nature, rendered or recommended by a psychiatrist, or medical in nature, rendered or recommended by a psychiatrist or other physician... e. Rehabilitative services;
f. Children’s mental health services;
g. Specialized therapeutic foster care, Level 1 and 2...
3. Services are limited to those covered services provided by or under the recommendation of a psychiatrist or physician and related to a plan of care provided or authorized by a psychiatrist or physician, as appropriate, based on the patient’s diagnosis.” Florida Mental Health RFP, pages 24-25.

“2.4 Additional Service Requirements
A. Community Treatment of Patients Discharged from State Mental Hospitals
The contractor shall provide medically necessary mental health services to enrollees who have been discharged from any state mental hospital...” Florida Mental Health RFP, page 25.

“The following is a summary list of the optional services which may be provided under the prepaid health plan contract as a downward substitution of care; none of these services will be compensated for separately by Medicaid under the contract...
Optional Services...
m. Drop-in/Self-help Centers...
s. Overlay...
t. Respite...
u. Sheltered Employment...
v. Supported Employment...
w. Supported Housing...
y. Specialized Therapeutic Foster Care...
z. Other Services (List)...” Florida Mental Health RFP, pages 94-96.

“30.720 Behavioral Health...
The health plan shall be responsible for providing comprehensive behavioral health services up to the benefit limits including: ...
* Methadone treatment services which include the provision of methadone or a suitable alternative (e.g. LAAM), as well as outpatient counseling services...
* Physician services
* Therapeutic services including:
* Occupational therapy
* Other medically necessary therapeutic services…” Hawaii RFP, pages 20-22.

“Is occupational therapy (bullet 1) only covered as part of an inpatient stay? If not, please further define the plan’s responsibilities in this area...

ANSWER:
Occupation and other therapy services are not limited to inpatient behavioral health stays. Occupational and other therapy services should be provided if they are medically necessary…” Hawaii RFP, Q&A, pages 13-14.

HIBH

“Bio-psycho-social rehabilitation - services which assist individuals to develop daily and community living skills, to set goals for themselves, to learn problem solving, to handle social relationships, and to utilize self-help group experiences.” Hawaii Behavioral Health RFP, page A2.

“Family/collateral support and education - services provided to a family either in a group with other families or with a family (with or without the client), to gain assistance/support of the family in treatment of the client: to coordinate or evaluate the implementation of treatment plan objectives; and to provide education to increase understanding and ability to cope with their seriously mentally ill family member…

Home bound services- evaluation and services provided by multi-disciplinary teams for clients in the home who exhibit 1) nability to go to clients/centers/facilities; 2) non-compliance with traditional services; 3) physical disability; 4) non-availability of transportation; 4) evidence that hospitalization will result if services are not provided. Excludes clients in inpatient and residential settings.” Hawaii Behavioral Health RFP, pages A4-A5.

“APPENDIX E
SERVICES AND MISCELLANEOUS ITEMS NOT COVERED BY THE HAWAII QUEST PROGRAM...
13. Psychiatric care and treatment for sex and marriage problems, weight control, employment counseling, primal therapy, long term character analysis, marathon group therapy, and/or consortium.” Hawaii Behavioral Health RFP, page E2.

“30.410 Required Providers...
The following is a listing of required components of the provider network. It is not meant to be an all-inclusive listing of the components of the network and additional components may be required based on the needs of the members...
* Mental health rehabilitation services
* Behavioral healthcare specialist services such as psychiatrists, psychologists, geriatricians, QMRPs or other professionals trained to manage MR/DD members, social workers, certified substance abuse counselors, counselors and nurses trained in psychiatry...
* Pre-vocational programs
* Social/recreational services
* Occupational therapy
* Interpretation services...
* Lodging and meals associated with obtaining necessary care” Hawaii Behavioral Health RFP, page 15.

“30.700 Scope of Behavioral Health Services...
The BHMC plan shall provide the full range of psychiatric inpatient, outreach treatment, rehabilitation and crisis response service services needed by SMI adults and SED children and youth…” Hawaii Behavioral Health RFP, page 25.
“30.710 Covered Behavioral Health Services...
At a minimum, the BHMC plan shall provide the services listed in this section below: ...
* Other practitioners services
* Other medically necessary practitioner services provided by licensed and/or certified healthcare providers
* Therapeutic Services including:
* Occupational therapy
* Other medically necessary therapeutic services including services which would prevent institutionalization
* Bio-Psycho-Social Rehabilitation services including:
* Work Assessment Service
* Intensive Day Treatment
* Day Treatment
* Pre-Vocational service including:
* Work Assessment service
* Pre-employment service
* Social/Recreational therapy services” Hawaii Behavioral Health RFP, pages 26 and 28.

“30.900 Other Services to be Provided
In addition to the behavioral health services listed in subsection 30.710 the plan shall provide certain specialized services. This section lists the required other services.
* Member Education...
* Culture/linguistic services
* Outreach

Outreach involves the provision of services wherever necessary to assure all eligible members receive needed behavioral health services, e.g. outreach to the homeless, homebound etc…” Hawaii Behavioral Health RFP, pages 31-32.

“(b) Covered Services...
(2) Medically Necessary Covered Services
The following services and benefits shall be included as Covered Services under this Contract and will be provided to Beneficiaries whenever medically necessary: ...
* Psychological testing...
* Subacute alcohol and substance abuse services, benefits may be limited as set forth in 77111. Adm. Code 2090* [* Subacute alcohol and substance abuse services shall be provided by Contractor’s employed Providers as set forth in 77 Ill. Adm. Code 2090. When such services are provided by non-employed Providers, such Providers shall be certified under 77111. Adm. Code 2090. In addition, the Contractor must allow group outpatient care visits to be substituted on a two-to-one basis for individual outpatient visits.]…” Illinois HMO Contract, pages 19-20.

“3.1.3 Medicaid Covered Services
The Indiana Medicaid program covers the following services for all eligible recipients. The specific services covered under the managed care initiative are specified in Section 4.4 of this RFP...
* Targeted case management services...
* Mental health rehabilitation...
* Long-term care...
* Mental hospital care for recipients under 21 years or over 65 years...
* Community mental health center services...
* Psychiatric hospital services for individuals under age 21 and individuals age 65 or older
* Psychiatric hospital services for individuals between age 21 and 65 in psychiatric facilities of sixteen beds or less…
* Hospice services…” Indiana RFP, pages 3-3 - 3-5.

IABH

“41.0 COVERED DIAGNOSES...
The following ICD-9 diagnosis codes are excluded from Iowa Plan coverage, unless the enrollee also has a diagnosis which is covered under the Iowa Plan:
      315 Specific delays in development
      316 Psychic factors associated with diseases classified elsewhere
      317 Mild mental retardation
      318 Other specific mental retardation
      319 Unspecific mental retardation” Iowa Behavioral Health Contract, pages 26-27.

41.0 COVERED DIAGNOSES...
Integrated Mental Health Services and Supports: Individualized mental health services and supports planned jointly by the Contractor and the enrollee, family members as applicable, and representatives of other service delivery systems; allows the Contractor flexibility to offer enrollees services which augment and complement those provided through other funders and systems; limited to services/supports specifically tailored to an individual enrollee’s need at a particular point in time and are not regularly defined services otherwise offered by the Contractor...

Psychiatric Rehabilitation Services: The services designed to restore, improve, or maximize level of functioning, self-care, responsibility, independence, and quality of life and to minimize impairments, disabilities and disadvantages of persons with a disabling mental illness. Services are focussed on improving personal capabilities while reducing the harmful effects of psychiatric disability and resulting in consumers’ recovering the ability to perform a valued role in society...

Supported Community Living Services: The provision of those services and supports determined necessary to enable consumers with a chronic mental illness to live and work in a community setting. Services are consumer individualized, need and abilities focused, and organized according to the following components, which are to be provided by organizational staff through linkages with other resources: outreach to appropriate support or treatments services; assistance and referral in meeting basic human needs; assistance in housing and living arrangements; mental health treatment; crisis intervention and assistance; social and vocational assistance; support, assistance and education to the consumer’s family and to the community; protection and advocacy; coordination and development of natural support systems; and service coordination. Services are directed to enhancing the consumer’s ability to regain or attain higher levels of independence, or to maximize current levels of functioning.” Iowa Behavioral Health Contract, pages 49, 50, 52.

“ATTACHMENT ON MENTAL HEALTH SERVICES
Covered Mental Health Services...
* Psychiatric nursing services by a home health agency...
* Mental health services determined necessary subsequent to a EPSDT screening…

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 people with mental health diagnoses...
* Services of a licensed social worker for treatment of mental illness...
* Mobile counseling services...
* Psychiatric rehabilitation services...
* Peer support services for persons with chronic mental illness
* Supported Community Living Services
* Reimbursement to appropriately credentialed/trained clinicians for administration of an appropriate level of functioning assessment to each Iowa Plan enrollee who meets the criteria of either a child with a serious emotional disability or a person with serious and persistent mental illness; the scale shall be repeated at intervals recommended by the selected scale; the final determination of the scales shall be made by DHS following negotiation with selected Contractor and the Iowa Plan Advisory Committee
* Programs of Assertive Community Treatment” Iowa Behavioral Health Contract, pages 79, 81.

“I. COVERED AND REQUIRED SUBSTANCE ABUSE SERVICES
The Contractor shall develop a network of providers to assure availability of the following services listed for both adults and children, on a statewide basis...
15. PMIC Substance Abuse Services consisting of treatment provided by a substance abuse licensed PMIC and consistent with the nature of care provided by a PMIC as described in Iowa Code chapter 135H. (Medicaid enrollees only)
20. All services appropriately provided as part of substance abuse treatment. Such services would vary according to the level of service, and may include, but not necessarily be limited to the following:
* lodging and dietary services...
* rehabilitation therapy and counseling...
* diagnostic urine or blood testing, specific to substance abuse treatment...
22. Substance abuse treatment services determined necessary subsequent to an EPSDT screening meeting OBRA89 requirements. (Medicaid enrollees only)...
27. Court ordered treatment which meets criteria for treatment services (except for adult Medicaid enrollees at a state mental health institute)” Iowa Behavioral Health Contract, pages 84, 85.

“D. Services to Be Provided
1. Covered Services
The Contractor shall provide Covered Services in accordance with Section 7.9.1 and Attachment VIII of the RFA.” Kentucky Contract, page 21.

“Behavioral health services covered by the managed care Contractors for the two waiver programs are described below: ... Emergency room services excluding psychiatric consultations provided by a psychiatrist, community mental health center clinician or other licensed or certified mental health practitioner.
Physical health services PRTF residents...
Physical health services to children in EPSDT residential settings
Physical health services to children in EPSDT residential settings...
All laboratory services
Supporting psychiatric services by home health agencies to recipients not served by a community mental health center
Behavioral health services provided by Hospice
Social services provided by primary care centers
CORF (Comprehensive Outpatient Rehabilitation Facility)
All hospital Medicare cross-over claims.” Kentucky RFA, pages 90-91.

“Chapter 62 Maryland Medicaid Managed Care Program: Definitions
.01 Definitions...
(12) ‘Behavior management treatment’ means, in the context of COMAR 10.09.69, an interdisciplinary approach which incorporates a combination of behavior modification, psychotherapy, and pharmacologic therapy which addresses problems interfering with learning, development, and social relationships...

(142) ‘Psychiatric rehabilitation program (PRP)’ means, in the context of COMAR 10.09.70, a program approved under COMAR 10.21.21...

(167) ‘Specialty mental health services’ means any mental health services other than primary mental health services.”
Maryland COMAR 10.09.62.01.

“Appendix C
Exhibit 2: Behavioral Health (BH) Services...
B. Diversionary Services—those BH services which are provided as alternatives to inpatient services, including: ...
1) Community Support for Adults, Children, and Adolescents—services provided in a community setting, which are used to prevent hospitalization, and designed to respond to the needs of Enrollees whose pattern of utilization of services or clinical profile indicated high risk of readmission into 24 hour treatment settings...” Massachusetts Contract, Appendix C, pages 5-9.

MABH

“SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…
Diversionary Services - shall mean those mental health and substance abuse services which are provided as alternatives to Inpatient Services and which satisfy all access, quality, and cost-effectiveness standards developed by the Contractor and approved by the Division.” Massachusetts MH/SAP Contract, Appendix A, pages 6, 8

“3.2 Delivery and Coordination of Services
The Contractor shall: ...
C. beginning January 1, 1997, unless otherwise agreed to by the Division, provide clinically appropriate access to services at alternative levels of care for Recipients, including but not limited to self-help/drop-in services for mental health; self-help/drop-in services for substance abuse treatment; transitional support services for substance abuse treatment; and mobile outreach for foster care families.” Massachusetts MH/SAP Contract, Appendix A, page 21.

“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: ...
e. treatment planning...
h. specialty services and programs, such as:
1. Dual Diagnoses;
2. DEP or ESP, whichever is appropriate;
3. homelessness;
4. PCC linkage;
5. peer & self-help groups; and
6. substance abuse programs for pregnant women.” Massachusetts MH/SAP Contract, Appendix B, page 29.

“5.11 Substance Abuse Services for Pregnant Women The Contractor shall:
5.11.01 Ensure that, at a minimum, the following substance abuse services for pregnant women with a substance abuse diagnosis are available: ...
e. community support programs...

5.11.02 Design and monitor a plan to maintain open access to the above-listed services as set forth in subsection 5.11.01. of Appendix B to this Contract...
5.11.05 Design and implement an ongoing training program to educate the contractor’s clinical staff and Network Providers regarding the specialized service needs of pregnant substance abuse women, which shall at a minimum, include education regarding substances typically used, standard treatment protocols, and other educational materials such as those developed by the coalition on addiction, Pregnancy, and Parenting (CAPP).” Massachusetts MH/SAP Contract, Appendix B, pages 47-48.

“APPENDIX C
COVERED SERVICES UNDER MH/SAP...
I. DMA Covered Services
B. Diversionary Services...
1. Community Support for Adults, Children, and Adolescents - shall mean services, provided in a community setting, which are used to prevent hospitalization and designed to respond to needs of individuals whose pattern of utilization of services or clinical profile indicates high risk of readmission into 24 hour treatment settings...
4. Family Stabilization - shall mean services which provide short-term flexible services to assist care-givers in stabilizing children and adolescents in home settings. These supportive services are delivered during an episode of acute mental illness or substance abuse or after out-of-home treatment, such as Inpatient Mental Health or Substance Abuse Services, for such an episode. These services are designed to divert services from hospital settings, prevent repeated hospitalizations or to allow children and adolescents to move from the hospital to a less restrictive setting more quickly.

D. Outpatient Services...
1. Mental Health
b. Mental Health Clinic Treatment...
4. Home Visits - shall mean crisis intervention, individual, group, or family therapy, and medication provided in the enrollee’s residence, when unable to be served at the Provider’s facility and as clinically appropriate...

E. Special Procedures
1. Electro-Convulsive Therapy - shall mean service which initiates seizure activity with an electric impulse while the individual is under anesthesia. It is administered in a hospital facility which is licensed to provide this service by the Department of Mental Health...

II. DMH Covered Services...
C. Emergency Services...
5. Specializing Services - shall mean therapeutic services provided to an individual, in a variety of settings, on a one-to-one basis to maintain the individual’s safety as a component of Emergency Services.” Massachusetts MH/SAP Contract, Appendix C, pages 1-8.

“5.1.1C.5: PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES...
c. Incentives Only…” Massachusetts MH/SAP Contract, Amendment 1, page 14.

“5) Expanded MassHealth Benefit Advocacy: DMH Consumers
The Contractor shall provide outreach to DMH Acute Care Consumers not already determined MassHealth eligible by sending MassHealth application material to and following-up with the consumer or his/her DMH case manager. For consumers who are eligible for DMH services as of July 1, 1997 (‘Known Consumers’), the Contractor shall target to complete such outreach activities within 90 days of the inception of MassHealth Expansion. For all new DMH acute care consumers (‘New Consumers’), the Contractor shall target to complete such outreach activities within 45 days of the Contractor’s receipt of the consumer’s DMH eligibility information...
e. Initiatives with Administrative Costs Only…

4) Expanded MassHealth Benefit Advocacy: DMH Consumers
The Contractor shall provide outreach to DMH Acute Care Consumers not already determined eligible by sending MassHealth application material to and following-up with the consumer or his/her DMH case manager...” Massachusetts MH/SAP Contract, Amendment 1, pages 16, 19.

“Section 6.1. MA and MinnesotaCare/MA Covered Services. The HEALTH PLAN shall provide, or arrange to have provided to MA and MinnesotaCare/MA Enrollees comprehensive preventive, diagnostic, therapeutic and rehabilitative health care services as defined in Minnesota Statutes… These services shall include but are not limited to, the following…

Section 6.1.16. Mental Health Services...
A. General Mental Health Services… The HEALTH PLAN must ensure that the following services are available to its Enrollees: ...
8) Neuropsychological rehabilitation and/or cognitive remediation training for Enrollees with a diagnosed neurological disorder who can benefit from cognitive rehabilitation services...
10) Therapeutic Support of Foster Care.
11) Family Community Support Services.” Minnesota Contract, pages 48-49.

“Section 6.15.9. Enrollees in Need of Gender Specific Mental Health and/or Chemical Dependency Treatment: The HEALTH PLAN must provide its Enrollees with an opportunity to receive mental health and/or chemical dependency services from the same sex therapist and the option of participating an all male/all female group therapy program...

Section 6.15.11. Developmentally Disabled (DD): specialized mental health and rehabilitative services and other appropriate services covered by MA. Such services may include: Family Planning Services adapted to the special needs of the developmentally disabled population, behavior management, rehabilitative and therapeutic services, pain management, or genetic counseling…” Minnesota Contract, pages 66.68.

“b. Covered Services...
17) Mental Health and substance abuse services…” Missouri RFP, page 9.

“The comprehensive benefit package includes: ...
bb. Early, periodic screening, diagnosis, and treatment (EPSDT) services also known as the Health Children and Youth (HCY) program provides services for individuals under the age of 21 years…
13) Mental health and substance abuse services as defined in Performance Requirements segment, Item 2.2, paragraph 2.6.1 cc…” Missouri RFP, page 50.

“cc. Mental health and substance abuse services are included in the comprehensive benefit package as follows: ...
4) Services shall include, but not be limited to: ...
* Alternative services which are reasonable, cost effective and related to the individual’s treatment plan.

5) Services provided by a Comprehensive Substance, Treatment and Rehabilitation (CSTAR) or Community Psychiatric Rehabilitation (CPR) provider shall be reimbursed by the state agency on a fee-for-service basis according to the terms and conditions of the Medicaid fee-for-service program.

PARAGRAPH 2.6.1 cc. 6) HAS BEEN ADDED BY AMENDMENT #002
6) The health plan is responsible for payment of behavioral health services as defined in this Request for Proposal that are court ordered and for involuntary commitments.” Missouri RFP, page 51.

“PSYCHOLOGY/COUNSELING
Health plans are financially responsible for providing medically necessary psychology and counseling services as specified in this RFP. A health plan is not responsible for behavioral health services for children who are in the care and custody of the State (Group 4 category of assistance)…” Missouri RFP, Attachment Five.

NEBH

“2.2 Scope: ...
The Rehabilitative Psychiatric Services (471 NAC 35-000), commonly referred to as the Medicaid Rehab Option, are not included in this contract.” Nebraska Behavioral Health Contract, page 3.

“4.1 Applicable Definitions: The following definitions apply under this contract: ... 4.1.26 The term ‘Mental Health and Substance Abuse (MH/SA) Package’ means the following MH/SA services that represent a minimum benefits package that must be provided by the Prepaid Health Plan to NHC clients who have a mental health or substance abuse condition: ...
(b) MH/SA Services for Children and Adolescents Age 20 and Younger (See 471 NAC 32-000), including: ...
(4) Treatment Foster Care Services...
(d) Client Assistance Program (See Section 11.41 of this contract);
(e) Individualized Alternative or Enhanced Services that allow the client to be in the least restrictive and most appropriate level of care, even if these services are non-traditional and do not meet the usual definition of ‘medical necessity’, and are not considered one of the Nebraska Medical Assistance Program’s ‘coverable’ MH/SA services pursuant to 471 NAC. These services must include, but are not limited to the following: ...
(2) Psychiatric nursing services
(3) Respite Care
(4) Client Assistance Program
(9) CTA/ Home-Health RN
(10) Native American Mental Health/Substance Abuse Programs...

(f) Lab, Radiology and Anesthesiology Services pursuant to a mental health/substance abuse diagnosis.” Nebraska Behavioral Health Contract, pages 6, 9-10.

“11.2 Governing NHC Regulations: ...
MH/SA services are provided by the Prepaid Health Plan (PHP) for all NHC clients. The MH/SA Package includes the following services: ...
(d) Client Assistance Program (See Section 11.41 of this contract);
(e) Individualized Alternative or Enhanced Services that allow the client to be in the least restrictive and most appropriate level of care, even if these services are non-traditional and do not meet the usual definition of ‘medical necessity’, and are not considered one of the Nebraska Medical Assistance Program’s ‘coverable’ MH/SA services pursuant to 471 NAC.
(f) Lab, Radiology and Anesthesiology pursuant to a Mental Health substance abuse diagnosis.” Nebraska Behavioral Health Contract, pages 51-52.

“11.6 Community-Based Care: The PHP shall provide care that is community-based and, when appropriate, involves a representative from the client’s community support system. This may include areas such as education, social services, law enforcement, religion, medical, and other MH/SA professionals. “ Nebraska Behavioral Health Contract,
page 53.

“11.12.1 Scope of Services: The PHP shall provide a full array of services along a continuum of care in accordance with 471 NAC 20-000 and 32-000, according to the following provisions:
(a) Services that are solution-focused, with time limited treatment and intervention, and that follow appropriate protocols for, but not limited to, treatment planning, transitional and discharge planning, clinical record-keeping, inspections of care, pre-treatment assessments, utilization review, after-care, care management, service coordination, travel to the home of handicapped individuals, provider payment, and appeals procedures according to 471 NAC…” Nebraska Behavioral Health Contract, page 56.

“11.41 Client Assistance Program: Maintain a Client Assistance Program with the following features:
(a) Direct client access to CAP services via walk-in or a toll-free telephone number. Prior authorization by the client’s PCP or the PHP is not required to access the CAP;
(1) The client is entitled to five CAP sessions per calendar year. The purpose of the CAP is to provide general outpatient counseling services, e.g., brief education, training, or behavioral intervention.
(2) In cases where appropriate treatment cannot be provided by the CAP provider, the client must be referred to more appropriate MH/SA through the Mental Health and Substance Abuse Service Evaluation and Review function. All services beyond the CAP must be prior authorized through the PHP.
(b) PHP registration of the CAP services and payment of CAP services utilizing an authorization number;
(c) A triage and referral function at the CAP access point. This function must be equipped to determine the appropriate level of CAP care and MH/SA provider for the client; and
(d) A monitoring and tracking function to determine client CAP utilization. Client utilization of CAP services must be reported to the Department within the time frames specified in the PHP contract for NHC.” Nebraska Behavioral Health Contract, pages 60-61.

“11.55.7 Lab, X-ray, and Anesthesiology Associated with MH/SA Services:
Services associated with the treatment of MH/SA services, and authorized by a MH/SA provider participating in the PHP’s network, such as lab fees, x-ray charges and the administration of anesthesiology, is the responsibility of the PHP, if the client is participating in the MH/SA component of the NHC.” Nebraska Behavioral Health Contract, page 69.

“G. Children With Special Health Care Needs and SED/SML...
2. Division of Child & Family Services (DCFS): …
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.)…” Nevada Contract, pages 23-24.

“Section I., Medical Services, Paragraph G. Child With Special Health Care Needs and SED/SMI...
3. Division of Child and Family Services (DCFS), b. Mental Health Services, paragraphs 3, 4, and 5 on page 24 are changed as follows:
‘Upon determination of SED or SMI, or reversal of SED or SMI determination, the child will remain enrolled with the Contractor. The Contractor must provide appropriate covered mental health services as determined medically necessary.

In the event the child is not determined SED or SMI, the Contractor must provide appropriate covered mental health services as determined medically necessary.’” Nevada Amendment #1, page 4.

“Covered Services
G. Mental Health (MH) and Substance Abuse (SA)...

2. Access
Coordination within the Plan for MH & SA Referrals: Access procedures shall include direct access to MH and SA Providers by self-referral, as well as State agency, school health personnel, and PCP referral. Access protocols shall include parameters for appointment availability (e.g., non-urgent care appointments within seven (7) days of Enrollee contact). Measurement shall be employed to assure compliance with established protocols.” New Hampshire General Agreement, Exhibit A.3., page 7.

“ARTICLE 10
COVERED HEALTH CARE SERVICES
10.1 For enrollees who are Medicaid-eligible through Title XIX or the NJ KidCare Plan A program, the contractor shall provide or shall arrange to have provided comprehensive, preventive, diagnostic, rehabilitative, and therapeutic health care services to enrollees that include all services that Medicaid recipients are entitled to receive pursuant to Medicaid, subject to any limitations and/or excluded services as specified in Appendix A of this contract. DMAHS shall assure the continued availability and accessibility of Medicaid covered services not covered under this contract. All services provided shall be in accordance with the New Jersey State Plan for Medical Assistance, the New Jersey Medicaid Managed Care Plan, and all applicable statutes, rules, and regulations.

10.1.1 For beneficiaries eligible solely through NJ KidCare Plan B and Plan C, the contractor shall provide the same managed care services and products provided to enrollees who are eligible through Title XIX. However, non-HMO covered services (i.e., services that continue to be provided fee-for-service) will be limited to certain services for the NJ KidCare Plan B and C populations as indicated in Appendix A.

10.1.2 For beneficiaries eligible solely through NJ KidCare Plan D, the contractor shall provide the managed care services and products as delineated in Appendix S. Non-HMO covered services (i.e., services that will be provided fee-for-service by the Division of Medical Assistance and Health Services) will be limited to the services delineated in Appendix S.

10.2 The contractor hereby agrees that no distinctions shall be made with regard to the provision of services to Medicaid enrollees and the provision of services provided to the contractor’s other non-Medicaid members unless required by this contract.

10.3 The scope of services to which an enrollee is entitled from the contractor, while deemed eligible for enrollment in the contractor’s plan, is those services included in the benefits package. The remaining services to which enrollees are entitled under the Medicaid program but are not included in the contractor’s benefits package will continue to be covered by Medicaid under its fee-for-service program.” New Jersey Contract, page 51.

“APPENDIX A...
BEHAVIORAL HEALTH FEE-FOR-SERVICE BENEFITS
NO CASE MANAGEMENT BY THE CONTRACTOR
The following behavioral health services would remain in the fee-for-service program without requiring case management by the contractor...
* Costs for Methadone and its administration...

INSTITUTIONAL FEE-FOR-SERVICE BENEFITS
NO CASE MANAGEMENT BY THE CONTRACTOR
The following institutional services will remain in the fee-for-service program without requiring case management by the contractor and are not covered for NJ KidCare Plans B & C...

EXCLUSIONS...
* Cost of methadone and its administration are excluded. The contractor will remain responsible for the medical care of members requiring substance abuse treatment.” New Jersey Contract, Appendix A, pages 169-171.

“APPENDIX S
NJ KIDCARE - PLAN D
BENEFITS PACKAGE-INCLUSIONS AND EXCLUSIONS...

EXCLUSIONS
Services not covered for NJ KidCare - Plan D participants include, but are not limited to: ...
22. Rehabilitative Services for Substance Abuse.” New Jersey Contract, Appendix S, pages 233-237.

“2.D.30.f Behavior Management Skills Development Services (BMSDS):
The benefit package includes behavior management services as set forth in the Medical Assistance division Program manual Section MAD-745.2, BEHAVIOR MANAGEMENT SKILLS DEVELOPMENT SERVICES.

2.D.30.g School-Based Services:
The benefit package includes counseling, evaluation, and therapy furnished in a school-based setting but not specified in the Individual Education Plan (IEP) or the Individualized family Services Plan (IFSP) as set forth in the in the Medical Assistance division Program manual Section MAD-747, SCHOOL-BASED SERSVICES FOR RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE.

2.d.30.i Treatment Foster Care Services:
Treatment Foster Care services as set forth in medical Assistance division Program manual Section MAD-745.1, TREATMENT FOSTER CARE.

2.D.31 Behavioral health Services Included only in the Benefit Package for Adults:

2.D.31.a Psychosocial Rehabilitation:
The benefit package includes psychosocial rehabilitation services as set forth in the Medical Assistance Division Program Manual Section MAD-310.35, MENTAL HEALTH REHABILITATION.” New Mexico Contract, pages 42-45.

“Prepaid Benefit Package
III. Definitions of Non-Covered Services...
B. Non-Covered Behavioral Health Services
1. Alcohol and Substance Abuse Services
a. Methadone Maintenance Treatment Program (MMTP)
Consists of drug detoxification, drug dependence counseling, and rehabilitation services which include chemical management of the patient with methadone. Facilities that provide methadone maintenance treatment do so as their principal mission and are certified by the Office of Alcohol and Substance Abuse Services under 14 NYCRR, Part 1040…

c. Outpatient Alcoholism Rehabilitation Services
Outpatient alcoholism rehabilitation programs provide full or half-day services to meet the needs of a specific target population…” New York Contract, Appendix K, pages K-25-K-27.

“ATTACHMENT L: COVERED SERVICES...
13. Mental Health services - includes… (5) The full range of therapy and rehabilitative services provided by state operated Regional Human Service Centers, (6) psychologist services… (8) any other appropriate and necessary mental health services.” North Dakota Contract, Attachment L, pages 1-2.

“D.2. Clarifications...
1. Mental Health Services...
MCPs must advise enrollees via the member handbook of the ability to self-refer to mental health services offered through community mental health centers (CMHCs). The community Medicaid-covered services include…community support programs...
2. Substance Abuse Services...
MCPs must advise enrollees via the member handbook of the ability to self-refer to substance abuse services offered through programs certified by the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) which are Medicaid providers.

The community Medicaid-covered services include …medical/somatic services…” Ohio RFP, pages 13-14.

“3. STATEMENT OF WORK
A. Subject to the provisions of this Section and Section 4, COVERED SERVICES...
Contractor shall:
(1) (a) Ensure provision of Medically Appropriate Covered Services consistent with OAR 410-141-0120, including
Emergency Services and preventive care services, in all those categories listed below as Mandatory and in those Optional categories that are listed below (hereinafter referred to as Capitated Services) for all OMAP Members: …

Chemical Dependency Services,
Outpatient- Chemical Dependency Services
Methadone/Lamm - Chemical Dependency Services
Outpatient CPMS - Chemical Dependency Services...” Oregon Contract, pages 2-3.

ORMH

“3. Mental Health Services Which Are Not Covered Services
Contractor shall assist its OMAP Members in gaining access to certain mental health services that are not Covered Services and that are provided under separate contract with the Division and/or OMAP. Services which are not Covered Services include, but are not limited to, the following:

a. Medical Transportation;
b. Medication;
c. DARTS Psychiatric Day Treatment for OMAP Members under 21 years of age (except for those services included in the Intensive Treatment Services Pilot Project);
d. Treatment Foster care reimbursed under BA code 030 for OMAP Members under 21 years of age;
e. Therapeutic Group Home for OMAP Members under 21 years of age;
f. Residential/Medical Youth Care Residential Center for OMAP Members under 21 years of age;
g. Behavioral Rehabilitative Services that are financed through Medicaid and regulated by SOSCF and OYA;
h. JCAHO Psychiatric Residential Programs for OMAP Members under 21 years of age (except for those services included in the Intensive Treatment Services Pilot Project);
i. Child and Adolescent Treatment Services (CATS) at the Oregon State Hospital (OSH) (except for those services included in the Intensive Treatment Services Pilot Project);
j. Investigation of OMAP Members for civil commitment;
k. Long Term Psychiatric Care in a state or other approved Psychiatric hospital for OMAP Members 21 years of age and older;
l. Preadmission Screening and Resident Review(PASRR) for OMAP Members seeking admission to a Nursing Home;
m. Extended care services for OMAP Members 18 years of age and older including Extended Care Management, Enhanced Care Services provided in SDSD licensed facilities, ‘365’ projects, Psychiatric Vocational Projects, PASSAGES Projects, and other services developed as less restrictive alternatives to Long Term Psychiatric Care at an Oregon State Hospital;
n. Personal Care in Adult Foster Homes for OMAP Members 21 years of age and older;
o. Other Residential Services for OMAP Members 21 years of age and older provided In Residential Care Facilities, Residential Treatment Facilities and Residential Treatment Homes;
p. Services provided to persons while in custody of a correctional facility or jail;
q. Abuse investigations and protective services as described in OAR 309-040-0200 through 309-040-0390, Abuse Reporting and Protective Services in Community Facility, and ORS 430.735 through ORS 430.765, Abuse Reporting for the Mentally Ill; and
r. Personal Care Services as described in OAR 411-34-000.” Oregon Mental Health Contract, pages 8-10.

“c. Rehabilitative Treatment Services
(1) Contractor shall establish and make available services for OMAP Members who have non- urgent or non-Emergency needs for Covered Services.
(2) Contractor shall establish written policies and procedures that ensure Covered Services which are Rehabilitative are provided within Medically Appropriate time frames...

e. Involuntary Psychiatric Care
(1) Contractor shall make reasonable effort to provide Covered Services on a voluntary basis and consistent with current Declaration for Mental Health Treatment in lieu of involuntary treatment.
(2) Contractor shall have written policies and procedures describing the appropriate use of Emergency Psychiatric Holds and alternatives to Involuntary Psychiatric Care to assure such holds are only used when a less restrictive voluntary service will not meet the Medically Appropriate needs of the OMAP Member and the behavior of the OMAP Member meets legal standards for the use of an Emergency Psychiatric Hold.
(3) Contractor shall only use psychiatric in-patient facilities and non in-patient facilities certified by the Division under OAR 309-33-0500, Standard for the approval of Facilities that provide Care, Custody and treatment to committed persons or to persons in Custody or on Diversion, to provide Emergency Psychiatric Holds. (4) Contractor shall comply with ORS Chapter 426, OAR 309-200-0000 through 309-200-0150, and OAR 309-205-0000 through 309-205-0050 for involuntary civil commitment of those OMAP Members who are civilly committed under ORS 426.130.
(5) Contractor shall administer Medication to OMAP Members held or civilly committed under ORS Chapter 426, regardless of setting, only as permitted by applicable statute and administrative rule. Contractor shall not transfer civilly committed OMAP Members to a state hospital for the sole purpose of obtaining authorization to administer Medication on an involuntary basis.” Oregon Mental Health Contract, pages 14-15.

“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)...
Flexible Service: A service that is an alternative or addition to a Traditional Service that is as likely or more likely to effectively treat the mental disorder as documented in the OMAP Member’s Clinical Record. Flexible Services include, but are not limited to: Respite Care, Partial Hospitalization, Subacute Psychiatric Care, Family Support Services, Parent Psychosocial Skills Development, Peer Counseling, and other nontraditional services identified...

Geropsychiatric Treatment Service: Four units at Oregon State Hospital Serving frail elderly persons with mental disorders, head trauma, advanced dementia, and/or concurrent medical conditions who cannot be served in community programs...

Group Skills Development: An individualized program of interventions designed to meet specific goals and objectives in an OMAP Member’s Treatment Plan and to remediate significant impairments in an OMAP Member’s functioning that are the result of a principal mental or emotional disorder…

Rehabilitative Services: Rehabilitative Services are any Medically Appropriate remedial services for the maximum reduction of a mental disability and attainment by the covered individual of his/her beat possible functional level...
Traditional Services: A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for per Capita Costs, October 1997 through September 1998. Traditional services are those services that have historically been used to treat mental disorders and include services for which Medicaid Fee-For Service billing categories exist. For OMAP Members under 21 years of age Traditional Services include the following...Multi Family Treatment Group; Individual Skills Development and Group Skills Development; Intensive Treatment, Structure and Support...For OMAP Members 21 years of age and older Traditional Services include the following: …Consultation…Daily Structure and Support; Individual and Group Skills Training…Covered Services provided in a variety of residential settings.” Oregon Mental Health Contract, Appendix K, pages K1, K9, K19, K21-K22.

“H. Coordination with Out-of-Plan Services...
9. Behavioral Health Services...
B. Behavioral Health Services Excluded from HealthChoices HMO Covered Services

The following services are not the responsibility of the HMO, under the HealthChoice Program.
* The behavioral health contractor (MCO) will provide access to diagnostic, assessment, referral, and treatment services for members for the following benefits: ... rehabilitation and half-way house services for drug/alcohol dependence/addiction…
* In addition to the mental health and drug and alcohol services covered by the behavioral health contract, supplemental mental health and drug and alcohol services are available through county mental health drug and alcohol authorities. The behavioral health contractor must arrange access to the following supplemental benefits, as available, for priority populations.

The supplemental benefits include: ...
Supported living services…” Pennsylvania RFP, pages 51-57.

PABH

“Request for Proposals (RFP) Definitions
For the purpose of this HealthChoices behavioral health services RFP, the definitions set forth shall apply...
Behavioral Health Rehabilitation Services for Children and Adolescents (formerly EPSDT ‘Wraparound’) - Individualized, therapeutic mental health intervention/services developed and recommended by an interagency team and prescribed by a psychiatrist or psychologist.” Pennsylvania Behavioral Health RFP, page 3.

“2) Service Categories for Rate Categories 1-7
For rate categories 1 through 7, there are 11 categories of service for which annualized utilization frequencies must be estimated. Specifically: ...
f) Behavioral health rehabilitation services for children and adolescents. The anticipated utilization should be expressed as the average numbers of behavioral health rehabilitation services (including but not limited to mobile therapy, therapeutic staff support, behavioral consultant, psychological and social services and other medically necessary services) per 1,000 eligible members…” Pennsylvania Behavioral Health RFP, pages 33-34.

“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: ...
11) laboratory studies ordered by behavioral health physicians...
13) effective July 1, 1997, the following will be in-plan services... b) family-based mental health services for children and adolescents...” Pennsylvania Behavioral Health RFP, pages 48-49.

“c. The MCO must establish processes to coordinate in-plan service delivery with services delivered outside the scope of services covered by the MCO:
1) Supplemental Behavioral Health Benefits...
The MCO must facilitate access to the following supplemental benefits, as available, for priority and special needs
populations.

The supplemental benefits include...
e) family-based mental health services for children and adolescents;
f) supported living services; g) family education and support services; e.g., respite care;
h) assistance in obtaining and retaining housing, employment, and income support services to meet basic needs;
i) continuous community based treatment teams...
k) community residential rehabilitation (CRR) services;
l) psychiatric rehabilitation with in-home capability and club houses;
m) consumer operated/directed self-help programs; e.g., drop-in centers, 12 step programs, double trouble groups...
o) child/adolescent support groups; e.g., ALATEEN, peer groups; and
p) social rehabilitation and companion programs; e.g., Compeer;
q) drug and alcohol transitional housing;
r) drug and alcohol drop-in-centers” Pennsylvania Behavioral Health RFP, page 51.

“3) Medical Care
The member’s HealthChoices HMO has a comprehensive benefit package provided in a manner comparable to the amount, duration, and scope set forth in the Medical Assistance fee-for-service program, unless otherwise specified by the Department, The comprehensive benefit package includes…other diagnostic and treatment services, outreach and follow-up, preventive care, home health services, and emergency transportation. Specific HMO in-plan benefits include: …physical examinations to determine abuse or neglect…Health Beginnings Plus, medical foster care; medical services to HealthChoices members placed in:
a) intermediate care facilities for persons with mental retardation (ICF/MR);
b) mental health residential treatment facilities (RTF);
c) extended acute psychiatric facilities;
d) non-hospital residential detoxification, rehabilitation and half-way house services for drug/alcohol dependence/addiction; and
e) juvenile detention facilities for up to 35 days…” Pennsylvania Behavioral Health RFP, page 53.

“SCHEDULE OF OUT-OF-PLAN BENEFITS...
Seriously and Persistently Mentally Ill (SPMI) Adults and Seriously Emotionally Disturbed (SED) Children... these individuals… will receive the following mental health services out-of-plan: ...
* Community psychiatric supportive treatment…
* Mobile treatment team...” Rhode Island RFP, Attachment B, pages 1, 3-4.

“2-3. Benefits/Service Requirements and Limitations...
c. Specialized Services...

3. MENTAL HEALTH/SUBSTANCE ABUSE SERVICES
Effective with implementation of the TennCare Partners Program, all mental health related services and substance abuse services provided to enrollees shall be the responsibility of Behavioral Health Organizations (BHOs) who have a contractual arrangement with the Tennessee Department of Mental Health and Mental Retardation. Mental health related and substance abuse services will no longer be the responsibility of the CONTRACTOR. These services include:
* Psychiatric Rehabilitation Services…” Tennessee Contract, pages 7-16.

“6.1 SCOPE OF SERVICES…
6.1.8 Non-Capitated Services. The following Texas Medicaid program services have been excluded from the services included in the calculation of HMO capitation rate: ...
Mental Health Rehabilitation…” Texas Contract, pages 33-34.

UTMH

“Article III
SCOPE OF SERVICES...
A. Covered Services
The CONTRACTOR will provide, at a minimum, all Medically Necessary Covered Services in accordance with the scope of services in the Utah State Plan and the Utah Medicaid Mental Health Centers Provider Manual, incorporated by reference. The manuals are available from the department upon request. Covered services include the following services: …
2. Mental health outpatient service including: ...
h. Skills development services…” Utah Mental Health Contract, page 4.

“B. Clarification of Covered Services...
3. Psychiatric services rendered by the psychiatrist in the emergency room are covered Services... 7. If electroconvulsive therapy is used by the CONTRACTOR as a treatment modality, the CONTRACTOR shall provide and pay for the procedure and the accompanying anesthesia...
15. Services for victims of domestic violence are Covered Services if, based on a mental health evaluation, it is determined mental health services are needed.
C. Clarification of Non-covered services...
8. Psychosocial counseling designed to help a pregnant woman cope with the stress that may accompany pregnancy is not a Covered Service. Such counseling is the responsibility of the client’s HMO or may be billed to DHCF on a fee-for-service basis by qualified providers. However, the CONTRACTOR is responsible to provide covered mental health services to pregnant women who are also suffering from an emotional or mental illness or disorder.
9. Psychiatric services ordered by an Enrollee’s non-PMHP physician while hospitalized in a non-psychiatric unit of a hospital are not Covered Services. Such services are the responsibility of the client’s HMO or may be billed to DHCF on a fee-for-service basis if the client is not enrolled in an HMO.” Utah Mental Health Contract, pages 6-8.

“EXCLUSIONS
The following services and supplies are excluded from coverage under this agreement. This shall not be construed to prevent the Contractor from covering any of these services when the Contractor determines it is medically necessary.
SERVICES COVERED BY OTHER DIVISIONS/ADMINISTRATIONS IN THE DEPARTMENT:
* Substance abuse treatment services covered through the Division of Alcohol and Substance Abuse...
* Nursing facility and community based services (e.g. COPES and Personal Care Services) covered through the Aging and Adult
Services Administration...
* Health care services covered through the Division of Developmental Disabilities for institutionalized clients.” Washington Contract, Exhibit 6, Attachment 1, pages 4-5.

“MEDICAID BENEFITS COVERED UNDER FEE-FOR-SERVICE MEDICAID
The following services are excluded from HMOs’ capitation rates, but will remain covered Medicaid services for the person who are enrolled in HMOs. The state will continue to reimburse the billing provider directly for these services on a fee-for-service basis...

MEDICAL SERVICE
Behavioral Health Services for Children Under Three

DEFINITION
Behavioral health services provided to children under the age of three including Early Intervention Services.

SCOPE OF BENEFITS
Services for children with handicapping conditions or children at risk for developmental delays due to biological, established or environmental factors. Level of intensity and settings determined by family and professionals.

LIMITATION ON SERVICES
Behavioral health services exclude services of psychiatrists and psychologists…” West Virginia Contract, Exhibit A, page 5.

“Behavioral Health Carveout
Prior to April 1996, all behavioral health services will be provided on a pay-for-service basis. Beginning in or after 1996, a behavioral health managed care organization (MCO) will provide behavioral health services on a capitated basis. These behavioral health services include the following:

MEDICAL SERVICE/ DEFINITION/ SCOPE OF BENEFITS/ LIMITATION ON SERVICES Personal Care/ Community care program for elderly/ Assistance with activities of daily living in a community living arrangement. Grooming, hygiene, nutrition, non-technical physical assistance, and environmental./ Limited on a per unit per month basis. Physicians order and nursing plan of care is required.” West Virginia RFA, Appendix A, page A7.