"SECTION D: PROGRAM
REQUIREMENTS
1. SCOPE OF SERVICES…
Behavioral Health: The Contractor shall provide behavioral health services as
described in Section D, Paragraph 2, Behavioral Health Services.
KidsCare Covered Services:
KidsCare members are eligible for the same services covered for members under
the Title XIX and state-only programs, with the following differences, exclusions
and/or limitations: ...
e. Behavioral health services are limited to 30 inpatient days
and 30 outpatient visits per contract year. (See details under Section
D Paragraph 2, Behavioral Health Services.)..." Arizona Contract,
page 10.
"2. BEHAVIORAL
HEALTH SERVICES
Title XIX (1931 group, SSI, SOBRA) and Title XXI (KidsCare) members are eligible
for comprehensive behavioral health services. The behavioral health benefit
for these members is provided through the ADHS Regional Behavioral Health Authority
(RBHA) system...
Member Education: … Covered
services for Title XIX and Title XXI are similar with the exception that non-emergency
transportation is not covered for Title XXI members. For Title XXI members
inpatient services and specified outpatient services are limited to 30 days/30
visits per contract year. Covered services include:
a. Inpatient services (Title XXI limited to 30 days per contract
year)
b. Individual, group and family therapy and counseling (limited
for Title XXI)
c. Psychotropic medication
d. Psychotropic medication adjustment and monitoring
e. Partial care, basic and intensive (limited for Title XXI)
f. Emergency crisis services
g. Behavior management (limited for Title XXI)
h. Psychosocial rehabilitation (limited for Title XXI)
i. Evaluation, screening and diagnosis (limited for Title
XXI)
j. Laboratory and radiology services for psychotropic medication
regulation and diagnosis
k. Emergency and medically necessary transportation (Title XXI
members limited to emergency transportation only)
l. Case management services
Referrals: ...
The Contractor is responsible for referring other Title XIX and Title XXI members
identified as needing behavioral health treatment services to the RBHA for evaluation
and provision of covered services…" Arizona Contract, page
16.
"P. Treatment
for Substance Abuse and Dependency
Treatment will cover medical detoxification for alcohol or substance abuse conditions.
Medical services including hospital services will be provided for the medical
non-psychiatric aspects of the conditions of alcohol/drug abuse."
Arizona Contract, page C4.
"1. SCOPE AND SERVICES...
Eligibility: Covered behavioral health services are available to all enrolled
Title XXI and acute care Title XIX members. Covered services include:
a. Basic Partial Care
b. Behavior Management
c. Case Management Services
d. Emergency/Crisis Behavioral Health Services
e. Evaluation and Screening
f. Group and Family Therapy and Counseling
g. Individual Therapy and Counseling
h. Inpatient Hospital
i. Inpatient Psychiatric Facilities for persons under 21 years of
age
j. Institutions for Mental Diseases (under 21 years of age and 65 years
and older)
k. Intensive Partial Care
l. Laboratory and Radiology Services for Psychotropic Medication Regulation
and Diagnosis
m. Psychosocial Rehabilitation
n. Psychotropic Medication
o. Psychotropic Medication Adjustment and Monitoring
p. Emergency Transportation…" Arizona Behavioral Health Contract,
page 10.
"ARTICLE II - DEFINITIONS...
S. Covered Services means Medical Case Management and those services set forth...
Covered Services do not include: ...
5. Mental health services as specified in Section 6.7.3.3, Mental Health.
6. Alcohol and drug treatment services and outpatient heroin detoxification
as specified in Section 6.7.3.4, Alcohol and Drug Treatment Services."
California Contract, pages 2-4.
"6.7.3.3 Mental
Health
All Specialty Mental Health Services (inpatient and outpatient) are excluded
from the Contract.
A. Contractor shall provide outpatient mental health services within the Primary Care Physician's scope of practice. Contractor shall provide assistance to Members needing Specialty Mental Health Services by referring such Members, whose mental health diagnosis is covered by the local Medi-Cal mental health plan or whose diagnosis is uncertain, to the local Medi-Cal mental health plan, if operational…" California Contract, page 116.
"6.7.3.4 Alcohol
and Drug Treatment Services
Alcohol and drug treatment services available under the Short-Doyle Drug Medi-Cal
program as defined in Title 22, CCR, Section 51341.1, and outpatient heroin
detoxification as defined in Title 22, CCR, Section 51328, are excluded from
this Contract.
The Contractor will arrange and coordinate Medically Necessary services, including referral of Members requiring alcohol and drug treatment to SD/MC alcohol and drug treatment programs including outpatient heroin detoxification providers. The Contractor will assist Members in locating available treatment Service Sites. To the extent that treatment slots are not available within the Contractor's geographical Service Area, the Contractor is encouraged to pursue placement outside the area." California Contract, page 118.
"EXHIBIT A
COVERED SERVICES…
NOT REQUIRED UNDER CONTRACT
Psychiatric/psychological care: Clients who live in counties included
in the Mental Health Capitation Program are required to seek services through
Mental Health Assessment and Service Agencies (MHASAS).
MHASAs are required to cover diagnoses and services as described in Section
A.16….
A.16 Mental Health And
Substance Abuse Services
Mental Health Services: Coverage for Mental Health Services shall apply if (1)
the Contractor's Service Area is not included in the Medicaid Mental Health
Capitation Program, and (2) the Client has a mental illness, as diagnosed through
a complete examination by a Physician or practitioner duly licensed to make
such a diagnosis and (3) treatment provided is necessary and appropriate for
the treatment of psychiatric conditions and crisis intervention.
a. Inpatient or partial hospitalization - Upon admission to a health care facility for services for the diagnosis and treatment of a mental illness: the period of stay for which benefits are payable shall be at least forty-five days for inpatient care or ninety days for partial hospitalization during a Contract Year with a properly authorized Referral…
Neurobiologically based mental illness: Coverage shall be provided for the treatment of neurobiologically based mental illness that is no less extensive than that provided for any other physical illness. Neurobiologically based mental illness means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder and panic disorder.
Autism. Benefits provided for the treatment of mental illness do not include autism, which shall be treated as a physical disorder.
Persons who are also enrolled in a Mental Health Capitation Program (MHCP) shall receive psychiatric services including but not limited to inpatient, outpatient, physician, assessment and case management services from the MHCP contractor and the HMO shall not be required to provide such services.
Detoxification services
a. Treatment for withdrawal from the physiological effects of alcohol
and drug abuse including detoxification.
b. In lieu of hospital inpatient detoxification, detoxification
may be provided at a Contractor-approved freestanding facility….
A.17 Exclusions
The following services are excluded from coverage hereunder:
PROCEDURE/SERVICE…
Inpatient or residential rehabilitation for substance or alcohol abuse."
Colorado Contract, Exhibit A, pages 2, 31-32.
"3.16 Mental Health
and Substance Abuse Access
a. The MCO shall provide, to its Members, all behavioral health care services
(mental health and substance abuse) covered by Medicaid that are medically necessary.
These services may be provided by the MCO through contracts with providers of
services or through subcontracted relationships with specialized behavioral
health management…" Connecticut Contract, page 25.
"SUMMARY DESCRIPTION
OF BENEFITS
A. Covered Services included in the Capitation Payment
1...
c. Mental health and substance abuse services in a general hospital
psychiatric unit are covered--regardless of the age of the individual.
2. Psychiatric (mental
health/substance abuse) Facility Inpatient Care
a. Medically necessary psychiatric hospital care, procedures, and
services as covered under DSS policy and regulation...
b… Such medically necessary care is only covered for individuals
under age 21 and 65 years of age or older. These services for individuals
aged 21 through 64 are noncovered services...
3. Freestanding Alcohol
Treatment Center Inpatient Care...
b. Services under the Medicaid program shall be for alcohol detoxification
and shall be limited to: a) the acute and evaluation phase of the treatment
program and b) a ten (10) day period for each occurrence...
c. Services must predominately focus on the medical and/or psychological
management of alcohol abuse and other medical or psychological conditions which
impact on or are related to alcohol abuse...
10. Psychological Services - Clinical, diagnostic, and remedial services personally performed by a psychologist. Services include: a) counseling and psychotherapy to individuals who are experiencing problems of a mental or behavioral nature and b) measuring and testing of personality, aptitudes, emotions, and attitudes...
31. Mental Health/Substance
Abuse Services - Medically necessary outpatient Mental Health and Substance
Abuse services provided by a licensed psychiatrist (or under the supervision
of a licensed psychiatrist) or other licensed or certified mental health practitioner.
Such services must be provided within the scope of the practitioner's license/certification.
a. Covered services include:
i. Initial evaluation (diagnostic);
ii. Mental health and substance abuse treatment services:
A) Individual psychotherapy;
B) Group psychotherapy;
C) Family therapy;
D) Specialized treatment, such as methadone maintenance and outpatient
detoxification; and
E) Partial hospitalization.
iii. Physical/neurological exams in connection with evaluation of
mental illness;
iv. Parent interview/group - Children's Mental Health Services;
v. Psychological testing - performed by licensed psychologists
only; and
vi. Neuropsychological evaluation performed by a qualified neuropsychologist.
b. Noncovered services: Hypnosis or electroshock therapy,
unless personally performed by a licensed practicing physician (M.D.)…"
Connecticut Contract, Appendix A, pages 3-15.
"Appendix L:
Bulletins, Memos and Policy Transmittals...
As you know, managed care organizations are responsible to provide substance
abuse treatment services to Medicaid eligible recipients under your contract
with the state…" Connecticut Contract, Appendix L, page 6.
"6.4 Basic Benefit
Package
The DHSSHP will provide standard benefits similar to the acute care benefits
that are currently provided under Delaware's Medicaid program. At a minimum,
MCOs must agree to assume responsibility for all covered medical conditions
within the Basic Benefit Package for each member. The package will include...
limited behavioral health services..." Delaware RFP, page II.37.
"Appendix H
Overview Medicaid Covered Services
SERVICE TYPE/ BASIC
BENEFIT PACKAGE
Mental Health/Substance Abuse
Adults
Inpatient/ 30 days
Outpatient/ 20 visits
Children
Outpatient/ 30 days" Delaware RFP, Appendix H, page 1.
"3.1 Describe the methods of delivery of the child health assistance using Title XXI funds to target low-income children: (Section 2102(a)(4))
Delaware SCHIP (SCHIP) program is targeted to children under age 19 with income at or below 200% of the Federal Poverty Level (FPL). The service package will include all of those basic benefit services provided under the State's Diamond State Health Plan (DSHP) (as it was structured during 1998) through the fully capitated managed care organizations (MCOs) participating with the DSHP… They will also receive 31 days of mental health and substance abuse treatment services (any treatment modality) in a calendar year in addition to the basic MCO benefit of inpatient care, children will become eligible for Medicaid long-term care services. Thus the SCHIP program will provide very high quality mental health and substance abuse coverage - coverage which is better by far than most private sector coverage. Services will be provided statewide with no variations based on geography…" Delaware RFP, Appendix A (SCHIP), page A.7.
"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.
6.2.11. 'X' Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) -30 days of outpatient care included in the basic MCO benefit. Additional days (up to 31) available through wrap-around. See note in 6.2.10." Delaware RFP, Appendix A (SCHIP), pages A.18-A.19.
"H. COVERAGE AND
BENEFITS
1. Covered services
a. This contract provide for coverage and provision by Provider
of all medical assistance benefits and services that are listed in Attachment
I, which is incorporated herein as part of this contract…
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 the enrollee's PCP. Provider shall document the provision of such
services in enrollees' medical records." District of Columbia Contract,
pages 21, 25-27.
"ATTACHMENT I
A. Services To Be Provided
1. Services. The plan shall insure the provision of the following covered
services as defined and specified in Attachment II:
Mandatory...Covered
Community Mental Health Services...X(Agency Area 6 only)
Mental Health Targeted Case Management...X (Agency Area 6 only)"
Florida Contract, page 5.
"2. Quality
and Benefit Enhancements. In addition to those covered services specified in
section A.1., Services, of this attachment, the plan shall offer those quality
and benefit enhancements to enrolled Medicaid recipients as specified below...
b. Substance Abuse: The plan shall have primary care physicians screen
members for signs of substance abuse as part of prevention evaluation.
Targeted members shall be asked to attend community or plan sponsored substance
abuse programs. The plan shall provide substance abuse screening training
to its providers on an annual basis..." Florida Contract, pages 6
- 7.
"4. Community
Mental Health Services
Community mental health services include mental health services and are provided
for the maximum reduction of the recipient's mental disability and restoration
to the best possible functional level. Such services must be rendered or recommended
by a psychiatrist or other physician and included in a treatment plan.
a. There are seven categories of services that must be provided under
community mental health:
(1) Treatment planning and review;
(2) Evaluation and testing services;
(3) Counseling, therapy and treatment services provided by a psychiatrist;
(4) Counseling, therapy and treatment services provided by a behavioral
health care provider;
(5) Rehabilitative services;
(6) Children's behavioral health services; and
(7) Day treatment services.
b. The DCF district Alcohol, Drug Abuse and Mental Health program offices will continue to fund community mental health services for children in specialized therapeutic foster care to the extent funds are available in the general appropriation act.
c. 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, base on the patient's diagnosis.
d. Such services do not include community mental health substance abuse services..." Florida Contract, pages 169-170.
"13. Community Mental Health Services. Community based rehabilitative services which are psychiatric in nature, rendered or recommended by a psychiatrist or other physician. Such services must be provided to plan members in agency area 6…" Florida Contract, page 84.
"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..." Florida Mental Health
RFP, page 21.
"2.6 Services
Not Covered...
The contractor shall not be responsible for... substance abuse treatment
or medical/surgical interventions associated with a psychiatric problem..."
Florida Mental Health RFP, page 31.
"30.410 Required
Providers...
* Behavioral health services such as therapy, counseling and substance
abuse services…" Hawaii RFP, page 9.
"30.720 Behavioral
Health
The health plan shall provide medically necessary mental health, drug abuse
and alcohol abuse services required by the adult QUEST member, within the established
limits specified below. A benefit year is defined as the period between
July 1 through June 30. Children are not subject to the behavioral health
limits because of EPSDT...
*A participating plan may,
at the plan's option, exceed the limits on behavioral health services.
The health plan shall provide an array of medically necessary behavioral health
(mental health, drug abuse and alcohol abuse ) preventive, diagnostic, therapeutic
and rehabilitative services within established limits to adult members.
The health plan is not obligated to provide behavioral health services to those
adult members who: 1) have been determined eligible for and have been
transferred to the BHMC plan, and/or 2) are the responsibility of the appropriate
State agency pursuant to a criminal commitment for evaluation or treatment under
the provisions of Chapter 706, HRS...
The health plan shall provide recipients with the appropriate levels and amounts of behavioral health care, up to the established limits. The health plan may, at the plan's option, exceed the limits on behavioral health services…" Hawaii RFP, pages 20, 22 & Hawaii RFP, Amendment 4.0.
"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. In
such a case, the health plan shall be relieved of its responsibility for providing
behavioral health services, but shall remain responsible for providing medical
services...
BHMC adult and child members who no longer meet the clinical criteria of being SMI or SED, shall be disenrolled from the BHMC plan. The health plan will be notified in writing of the members who will be disenrolled. Following disenrollment from the BHMC plan, the health plan becomes responsible for providing the appropriate mental health, drug abuse and/or alcohol abuse services within the established benefit limits...
31.200 Enrollment
into BHMC Plan
Once a member has been confirmed to meet the criteria for 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...
If the recipient no longer meets the criteria for enrollment in the BHMC plan, he/she shall be disenrolled from the BHMC plan at the end of the month and returned to the health plan. The health plan shall receive written notification of the disenrollment from the BHMC plan. At the time they are returned, the health plan assumes responsibility for providing all medical and behavioral health services within the established benefit limits." Hawaii RFP, pages 28-30.
"35.000 Provision
of Services - QUEST-NET...
* 6 mental health outpatient visits (alcohol and substance abuse services are
treated as mental health visits. Six of the 12 outpatient medical visits
may be substituted for six additional mental health visits)…" Hawaii RFP,
pages 40-42.
"APPENDIX L
PERSONS WITH SERIOUS MENTAL ILLNESS
Definition
The seriously mentally ill are defined as persons who, as the result of a mental
disorder, exhibit emotional, cognitive, or behavioral functioning which is do
impaired as to interfere substantially with their capacity to remain in the
community without supportive treatment or services of a long-term or indefinite
duration. In these persons, mental disability is server and persistent
resulting in a long term limitation in their functional capacities for primary
activities of daily living such as interpersonal relationships, self-care, homemaking,
employment, and recreation.
Conditions such as mental retardation or substance abuse may cause similar problems or limitations, and are not to be included in this definition unless, in addition to one or more of these disorders, the person has a severe and persistent mental disorder.
Criteria
Assessment:
The person has undergone a comprehensive professional clinical assessment sufficient
to establish a diagnosis of mental disorder and a quantitative functional assessment.
The combination of diagnosis and level of functioning establishes eligibility
for public services through a formula stated below…" Hawaii RFP,
Appendix L, page 1.
"Who will be financially responsible for behavioral health services required by members who are referred for SMI/SED evaluation, when the determination is not made within the time frame specified in this paragraph? ...Who is responsible for services rendered to an adult member who exhausts his/her benefits while awaiting and SMI evaluation?
ANSWER:
The QUEST plan will be financially responsible... The QUEST plan is responsible
for an adult who exhausts his/her benefits while awaiting an SMI evaluation."
Hawaii RFP, Q&A, pages 17-18.
"20.310 QUEST
Health Plan: Behavioral Health Coverage
The QUEST health plans are required to provide an array of medically necessary
behavioral health (mental health, drug abuse and alcohol abuse) preventive,
diagnostic, therapeutic and rehabilitative services within established limits
below to adult members…" Hawaii Behavioral Health RFP, page 5.
"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...
• Substance abuse services…" Hawaii Behavioral Health RFP, page 15.
"30.710 Covered
Behavioral Health Services...
At a minimum, the BHMC plan shall provide the services listed in this section
below: ...
• All medically necessary alcohol and chemical dependency services excluding
residential treatment services…" Hawaii Behavioral Health RFP, pages
26 and 27.
"Behavioral health services - services provided to person who are emotionally disturbed, are mentally ill, abusive or are addicted to alcohol and non-prescription drugs." Hawaii Behavioral Health RFP, page A1.
"(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:
...
• Inpatient psychiatric care...
• 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…" Indiana
RFP, pages 3-3 - 3-5.
"4.4 Description
of Managed Care Services
4.4.1 Hoosier Healthwise RBMC Covered Services
Covered services under Hoosier Healthwise RBMC include all Medicaid covered services with the exception of mental health, dental care, long-term institutional care, services provided as part of an Individualized Education Plan (IEP) pursuant to the Individuals with Disabilities Education Act (IDEA) at 20 U.S.C. 1400 et seq., substance abuse and chemical dependency services, and hospice services. The MCO must arrange and assure the provision of all RBMC covered services except self-referral services. For additional information about self-referral services, refer to Section 4.4.2.4 of this RFP. Detailed explanations of covered services and limitations are cited in Title 405, Article 5 of the Indiana Administrative Code that is on file in the Procurement Library. The Procurement Library also contains a copy of the Indiana Medicaid over-the-counter (OTC) drug formulary." Indiana RFP, page 4-4.
"CHIP Benefit Package
Service: Outpatient mental health/substance abuse services+
Indiana Medicaid Benefits: Includes mental health services provided by physicians, psychiatric wings of acute care hospitals, outpatient mental health facilities and psychologists endorsed as Health Services Providers in Psychology. Office visits limited to a maximum of 4 per month or 20 per year per recipient without prior approval.
CHIP Benefit Package: Covers outpatient mental health/substance abuse services when the services are medically necessary for the diagnosis or treatment of the recipient's condition except when provided in an institution for mental diseases. Office visits limited to a maximum of 30 per year per recipient without prior approval to a maximum of 50 visits per year.
Service: Inpatient mental health/substance abuse services**+
Indiana Medicaid Benefits: Each patient admitted must have an individually developed plan of care developed by the physician and interdisciplinary team. Plan of care must be reviewed and updated every thirty days by the interdisciplinary team. Rectification is required every 60 days.
CHIP Benefit Package: Inpatient mental health/substance abuse services are covered when the services are medically necessary for the diagnosis or treatment of the recipient's condition except when they are provided in an institution for mental diseases with more than 16 beds.
**Prior Approval Always
Required
*Prior Approval Required Under Certain Circumstances
+Federally Required CHIP Benefits." Indiana SCHIP Amendment, Attachment
C-1, page 4.
"4.2.1 Covered Services...
When mental health or substance abuse services are the responsibility of the
HMO, as defined in Articles 4.8 and 4.9 respectively of this Contract, services
shall be offered similar to the continuum provided by the Iowa Plan."
Iowa Contract pages 17-18.
"4.2.3 Services
Not Covered Under This Contract
The following services are not Covered Services: ...
- Mental Health Services covered by the Iowa Plan as outlined in 441 Iowa Administrative
Code 88, Division IV
- Substance Abuse Services covered by the Iowa Plan as outlined in 441
Iowa Administrative Code Chapter 88, Division IV…" Iowa Contract
pages 23-24.
"4.8 Mental
Health Services
The HMO shall refer Enrollees who are found to need mental health services to
the Iowa plan. The primary diagnosis shall be determined based on clinical
criteria. Applicable ICD-9 Codes are 290-302.9, 306-309.9, and 311-314.9.
However, the HMO shall provide mental health services for individuals whose
need for mental health services is secondary to a primary medical condition
in any given episode of care.
The Department will serve as an arbiter when service responsibility is questioned
by the HMO and/or Iowa Plan.
4.9 Substance Abuse
Services
The HMO shall refer Enrollees who are found to need substance abuse services
to the Iowa Plan. The primary diagnosis shall be determined based on clinical
criteria. Applicable ICD-9 Codes are 303.00 through 305.99.
The HMO shall provide substance abuse services for individuals whose need for
substance abuse services is secondary to a primary medical condition in any
given episode of care.
The Department will serve as an arbiter when service responsibility is questioned
by the HMO and/or Iowa Plan." Iowa Contract, pages 27-28.
"31.0 RISK RESPONSIBILITY
This Contract is a risk-based contract for Medicaid mental health and substance
abuse services in which the Contractor will be responsible for assuring, arranging,
monitoring, and reimbursing all necessary and appropriate mental health and
substance abuse services and supports for all enrolled Medicaid beneficiaries
as specified in this Contract.
The Contractor also will be at risk in administering services for persons with a mental health indicator who are designated as members in the State Payment Program (SPP) and for assuring, arranging, monitoring, and reimbursing all necessary and appropriate mental health services for persons determined eligible for SPP." Iowa Behavioral Health Contract, page 16.
"36.1 MEDICAID BENEFICIARIES
ENROLLED IN THE IOWA PLAN...
Coverage of the month of application means the Contractor will have responsibility
for paying for appropriate mental health and substance abuse treatment services
and supports for persons who may not have been determined as an enrollee at
the time the person requests services…" Iowa Behavioral Health Contract,
page 24.
"39.0 IOWA PLAN
SERVICES
Mental Health Services covered by the Iowa Plan and for which Contractor shall
be responsible are set forth in Attachment titled 'Mental Health Services.'
Substance Abuse Services covered by the Iowa Plan and for which Contractor shall
be responsible are set forth in Attachment titled 'Substance Abuse Services.'
40.0 STATE PAYMENT
PROGRAM
The Contractor shall be responsible to assure, arrange, monitor and reimburse
the delivery of State Payment Program (SPP) services to those persons with state
case status who carry a mental health indicator (MI or CMI) as determined by
the DHS Division of Mental Health/Developmental Disabilities. The Contractor
shall make available to an SPP member all services which are available to such
members pursuant to the county management plan which covers that person...
41.0 COVERED DIAGNOSIS
The Contractor is responsible for authorizing appropriate short- and long-term
services for Medicaid enrollees who have the following diagnosis series as defined
in the ICD-9-CM. Substance abuse diagnoses are indicated in italics:
290 Senile and presenile organic
psychotic conditions
291 Alcoholic psychoses
292 Drug psychoses
293 Transient organic psychotic
conditions...
The following ICD-9 diagnosis
codes are excluded from Iowa Plan coverage, unless the enrollee also has 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
41.1 COVERED SUBSTANCE
ABUSE DISORDERS FOR DPH PARTICIPANTS
The contractor will be responsible for providing necessary covered and required
services for the substance abuse treatment needs of DPH participants who have
the following substance abuse disorders:
a) Non-Dependent Abuse of Alcohol
b) Alcohol Dependency
c) Drug Dependency
d) Non-Dependent Abuse of Drugs
e) Intervention for Significant Others when there us no identified diagnosed
substance abuse client" Iowa Behavioral Health Contract, pages 26-27.
"PMIC Substance Abuse Services: Substance abuse 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." Iowa Behavioral Health Contract, page 50.
"I. COVERED
AND REQUIRED SUBSTANCE ABUSE SERVICES
Contractor must provide and assure access to a full range of continuum of substance
abuse treatment and related services. This includes, at a minimum, necessary
substance abuse care as was provided to the DPH population in the DPH substance
abuse treatment delivery system prior to the implementation of the IMSACP; for
Medicaid enrollees, at least those services which are included in the State
Medicaid plan and are provided in the Medicaid fee-for-service system.
The Contractor shall provide at least as much access to medically necessary substance abuse treatment for enrollees as was provided in the Medicaid fee-for-service delivery system prior to the implementation of the Iowa Managed Substance Abuse Care Plan. The Contractor may not sets limits on the amount, scope or duration of these services for enrollees other than those which are allowed in 441 Iowa Administrative Code Chapter 78 and Iowa Medicaid State Plan…" Iowa Behavioral Health Contract, page 84.
"B. MEDICAL SERVICES
NOT INCLUDED IN THE CONTRACT
The following services are non-covered under the terms of this contract, but
are covered under Fee-For-Service in the Medicaid Program: ...
• Alcohol and Drug Abuse Services with the exception of Acute Medical
Detoxification...
• All mental health services including psychiatrists, psychologists, Community
Mental Health Center (CMHC) services, Partial Hospitalization Services, and
mental health prescriptions including specific medications
• Behavioral management services…" Kansas Contract,
pages 3-4.
"10.09.64.07...
.07 Access and Capacity: Contracts and Provider Applications.
An MCO applicant shall include in its application the following information
or descriptions: ...
E. Written evidence
of the applicant's organizational capacity to provide special programs adequate
to meet the individual needs of all enrollees, including: ...
(4) Substance abuse services...
(6) All Medicaid-covered services required to comply with State statutes
and regulations mandating health and mental health services for children in
State-supervised care…" Maryland COMAR 10.09.64.07.
"10.09.65.11...
.11 Special Needs Populations-Individuals in Need of Substance Abuse Treatment.
A. An MCO shall meet the standards set forth in this regulation for identifying,
treating, and referring individuals in need of substance abuse treatment.
B. An MCO shall provide a continuum of substance abuse treatment services that offers access to the most appropriate level of individualized care to each enrollee...
C. An MCO shall make available to enrollees information on how to obtain substance abuse treatment services included in the basic health care package.
D. An MCO shall use a screening instrument comparable to the Michigan Addiction Screening Test (MAST) or C.A.G.E…" Maryland COMAR 10.09.65.11.
"10.09.67.10...
.10 Benefits-Substance Abuse Treatment Services.
A. An MCO shall provide to its enrollees medically necessary and appropriate
comprehensive substance abuse treatment services in accordance with the standards
set forth in COMAR 10.09.65.11-.11-2, including but not limited to:
(1) Evaluations, performed by a provider that is qualified under §B
of this regulation, to determine the nature and severity of an enrollee's substance
abuse problem and the appropriate level and intensity of care...
(2) Outpatient substance abuse treatment;
(3) Detoxification treatment, on either an outpatient, or, if medically
necessary and appropriate, an inpatient basis;
(4) For enrollees younger than 21 years old, residential substance abuse
treatment in an intermediate care facility-alcoholic (ICF-A), with a length
of stay determined by medical necessity;
(5) For pregnant and postpartum substance-abusing enrollees, outpatient
substance abuse treatment…" Maryland COMAR 10.09.67.10.
"10.09.67.26...
.26 Benefits-Primary Mental Health Services.
An MCO shall provide to its enrollees medically necessary and appropriate primary
mental health services, including appropriate referrals to the Department's
specialty mental health delivery system, as described in COMAR 10.09.70.
.27 Benefits-Limitations.
A. An MCO is not required to provide any of the benefits or services listed
in §B of this regulation.
B. The benefits or services not required to be provided under §A
of this regulation are as follows: ...
(5) Specialty mental health services, including IMD services...
(7) ICF-MR services…" Maryland COMAR 10.09.67.26-.27.
"SECTION 1. DEFINITION
OF TERMS...
Behavioral Health (BH) Program - a program for the administration, coordination,
and delivery of Behavioral Health MCO Covered Services as defined in Appendix
C of the Contract and that includes the following functions: service authorization,
Utilization Management and review, Quality Management, service delivery through
Provider Network, claims processing, management information systems (MIS) operation
and reporting, Network Management, Benefit Coordination, and state agency service
coordination.
Behavioral Health Services or BH Services - MassHealth Behavioral Health Services that are MCO Covered Services and are set forth in detail in Appendix C, Exhibit 2 of the Contract...
BH Inpatient Services - mental health or substance abuse services, or both, set forth in Appendix C, Exhibit 2 of the Contract, which are provided in a twenty-four hour setting, such as a hospital or freestanding detoxification facility.
BH Outpatient Services - mental health and substance abuse services set forth in Appendix C, Exhibit 2 of the Contract, which are provided in an ambulatory care setting, such as a mental health or substance abuse clinic, hospital outpatient department, community mental health center, or Provider's office…" Massachusetts Contract, pages 6-7.
"Section 2.12
Behavioral Health (BH) Program Services...
The Contractor shall develop and implement either directly or by entering into
a Material Subcontract(s) a MassHealth Behavioral Health Program. The
BH Program shall be designed to ensure all Medically Necessary BH Services are
provided to Enrollees based on their individual needs and consistent with Appendix
C, Exhibit 2. The Contractor shall establish and maintain structures and
processes to support management of BH Services on this basis. The provision
of BH Services shall be based on prevailing clinical knowledge and the study
of data on the efficacy of treatment…" Massachusetts Contract, page
68.
"3.2. Delivery and
Coordination of Services
The Contractor shall:
A. be responsible for ensuring the delivery of all the Covered Services
listed in Appendix C to this Contract without modification;
B. arrange, coordinate, and authorize the provision of all Medically Necessary
Covered Services listed in Appendix C to this Contract..." Massachusetts
MH/SAP Contract, Appendix A, page 21.
"SECTION II
WORK STATEMENT
II-A BACKGROUND/PROBLEM STATEMENT...
2. Managed Care Direction
Under the Comprehensive Health Care Program (CHCP), the State selectively contracts
with Contractors who will accept financial risk for managing comprehensive care
through a performance contract….
There are two categories of specialized services that are available outside of the CHCP. These are behavioral health services… These specialized services are clearly defined as beyond the scope of benefits that are included in the CHCP…" Michigan Contract, page 12.
"II-H SCOPE
OF COMPREHENSIVE BENEFIT PACKAGE
1. Services Included...
The services provided to Enrollees under this Contract include, but are not
limited to, the following: …
Mental health care up to 20 outpatient visits per Contract year…
3. Services covered
Outside of the Contract
The following Services are not Contractor requirements: ...
*Inpatient hospital psychiatric services (Contractors are not responsible for
the physician related to providing psychiatric admission physical and histories.
However, if physician services are required for other than psychiatric care
during a psychiatric inpatient admission, the contractor would be responsible
for covering the cost, provided the services has been prior authorized and is
a covered benefit.)
*Outpatient partial hospitalization psychiatric care
*Mental health services in excess of 20 outpatient visits each contract year
*Substance abuse services through accredited providers including:
*Screening and assessment
*Detoxification
*Intensive outpatient counseling and other outpatient services
*Methadone treatment…" Michigan Contract, pages 20, 22.
"Section 3.2.3. Enrollment
Materials…
3) A description of how the Enrollee may obtain services, including
… procedures for obtaining Medical Emergency care, Urgent Care, and Out of Plan
care, including a 24-hour telephone number
for Medical Emergency Services...
7) A description of the HEALTH PLAN's obligation to assume financial responsibility and provide reimbursement for Medical Emergency Services, Post-Stabilization Care Services and Out of Area Urgent Care." Minnesota Contract, page 24.
"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 6.1.2. Chemical Dependency (CD) Treatment Services. CD treatment services does not include detoxification (unless it is required for medical treatment), halfway house care, extended care and transitional care. Notwithstanding Section 6.21.2., CD services shall be provided in accordance with Minnesota Rules, Part 9530.6600 to 9530.6660 and by programs and facilities licensed under Minnesota Rules, Part 9530.5000 to 9530.6400, and Part 9530.4100 to 9530.4450...
Section 6.1.16. Mental Health Services. In approving and providing mental health services, the HEALTH PLAN shall use a definition of medical necessity that is no more restrictive than the definition of medical necessity found in Minnesota Statutes, Section 62Q.53 or described in Section 2.32.
A. General Mental Health Services. Mental health services must be provided in accordance with Minnesota Rules, Part 9505.0323 (MA payment for outpatient mental health services). Mental health services should be directed at rehabilitation of the client in the least restrictive clinically appropriate setting. The HEALTH PLAN must ensure that the following services are available to its Enrollees:
1) Diagnostic assessment,
psychological testing, and explanation of findings...
2) Crisis intervention...
3) Day treatment, partial hospitalization, and in-home family based mental
health services.
4) Individual, family, and group therapy and multiple family group psychotherapy...
5) Inpatient and outpatient treatment.
6) Assessment of Enrollees whose health care seeking behavior and/or mental
functioning suggests underlying mental health problems.
7) Neuropsychological assessment.
8) Neuropsychological rehabilitation and/or cognitive remediation training
for Enrollees...
9) Medication management.
10) Therapeutic Support of Foster Care.
11) Family Community Support Services." Minnesota Contract,
pages 48-50, 54-55.
"Section 6.2. GAMC Covered Services. The HEALTH PLAN shall provide, or arrange to have provided to 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 6.2.2. Chemical
Dependency Treatment Services, as specified in Section 6.1.2…
Section 6.2.13. Mental Health Services, as specified in Section 6.1.16."
Minnesota Contract, pages 59-60.
"Section 6.3.2. MinnesotaCare Enrollees. The HEALTH PLAN shall provide, or arrange to have provided to MinnesotaCare Enrollees the same services described in Section 6.1. Above with the following modifications.
D. Outpatient mental health services covered are limited to diagnostic assessments, psychological testing, explanation of findings, medication management by a physician, day treatment, partial hospitalization, and individual, family, and group psychotherapy." Minnesota Contract, page 61.
"2.1.5 Services shall
include...
t. Behavioral health (mental health and substance abuse) services as defined
in Performance Requirements segment, Item 2.2, paragraph 2.6.1 cc."
Missouri RFP, page 18.
"cc. Mental
health and substance abuse services are included in the comprehensive benefit
package as follows:
1) For children under the age of 21 covered services under the MC+ within
Category of Aid 4, Other Medicaid Children, behavioral health services, if medically
necessary, shall not be the financial responsibility of the health plan and
will be provided as outlined in paragraphs 2.11.8a through 2.11.8c...
2) All other members shall have all medically necessary behavioral health services included in the comprehensive benefit package. The state agency in conjunction with the Department of Mental Health has developed an array of services with an emphasis on the least restrictive setting. Health plan shall consider, when appropriate, using such an array of services in lieu of using an out of home placement setting for members enrolled in the health plan." Missouri RFP, page 51.
"2.5 PROVISION OF
SERVICES
2.5.1 COVERED SERVICES...
HMO COVERED SERVICE/DESCRIPTION
EPSDT: (recipients under 21)
Includes, but not limited to: ...
- drug/alcohol treatment/- covered for children with severe medical problems;
ARM 46.12.565 & 566." Montana Contract, page 40.
"HMO COVERED SERVICE/DESCRIPTION
Hospital Services [inpatient] (all persons)/services offered in a hospital,
limited to medically
necessary stays, including inpatient drug and alcohol detoxification; ARM 46.12.503
& 504." Montana Contract, page 41.
"2.5.2 Non-Covered
Services:
HMO NON-COVERED SERVICES/DESCRIPTION
Mental Health Conditions with the following primary diagnosis: ICD-9-CM
codes: ...
Mental Health Services/ Where the primary diagnosis defined under 'Mental Health
Conditions':
- psychologists
- social workers
- licensed professional counselors
- community mental health centers
- institutions for mental disease
- targeted case management for severely emotionally disturbed children
targeted case management for the chronically mentally ill
- residential treatment center
- therapeutic group home
- therapeutic foster care
- outpatient chemical dependency treatment (non- hospital based)."
Montana Contract, pages 46-47.
"4.1 Applicable Definitions:
The following definitions apply under this contract: ...
4.1.3 The term "Basic Benefits Package", means the following medical/surgical
services, representing a minimum benefits package, as defined in this contract
and 471 Nebraska Administrative Code (NAC), that shall be provided by
the plan to clients enrolled in the NHC:...
(r) Transitional MH/SA services (See 471 NAC 20-000 and 32-000 and Section 13.49
of this contract)…" Nebraska Contract, page 7.
"9.2.4 NHC Components:
...
The Mental Health and Substance Abuse (MH/SA) Services component of the NHC
shall be provided on a statewide basis as a 'carve-out' from the Basic Benefits
Package. The provision of MH/SA services is not part of this contract, except
as specifically described." Nebraska Contract, page 32.
"13.45 Services in
the Basic Benefits Package: Pursuant to this contract, services included in
the Basic Benefits Package are...
(r) Transitional MH/SA services (See 471 NAC 20-000, 32-000 and 13.49 of this
contract)…" Nebraska Contract, page 95.
"13.46 NHC Excluded
Services: The following Medicaid-coverable services are excluded from the NHC
Basic Benefits Package and are not the responsibility of the plan:
(g) Mental Health/Substance Abuse (MH/SA) Services (See 471 NAC 20-000 and 32-000),
except as addressed in Section 13.49 of this contract)…" Nebraska
Contract, page 96.
"2.1 Objective: The objective of this contract is to formally define the responsibilities of the contractor as a Prepaid Health Plan (PHP), in providing the Mental Health and Substance Abuse (MH/SA) Package for the NHC on a statewide basis, pursuant to this contract. The MH/SA Package is provided through a single PHP." Nebraska Behavioral Health Contract, page 3.
"CONTRACTOR DUTIES AND
RESPONSIBILITIES
I. Medical Services
A. Contractor Mandatory Managed Care Benefit Package. Except as
otherwise provided for in this contract, each Contractor must provide a comprehensive
managed care benefit package to Medicaid participants…
B. Contractor Covered
Services. At a minimum, the Contractor must provide directly or by subcontract
all medical services listed below: ...
19. Mental Health Services
1. Inpatient Psychiatric Hospital;
2. Mental Health, Outpatient/Public;
3. Mental Health Rehabilitative Services;
4. Psychologist;
5. Outpatient Psychiatric." Nevada Contract, page
21.
"Covered Services
I. Covered Services-General...
I. Mental Health/Substance Abuse Services
1. Outpatient Services:
Mental Health Services shall include services to comply with RSA 417.E.
These visits include short term evaluation, crisis intervention, individual
therapy, group therapy and family therapy when provided by a psychiatrist, a
psychologist, a clinical social worker, a certified clinical specialist in psychiatric
and mental health nursing, or a licensed pastoral counselor. The treatment plan
will be determined by a Plan Provider.
2. Inpatient Services:
Contractor will cover individuals under age twenty-one (21) and over
age sixty-five (65) years up to thirty (30) days of inpatient care in a private
mental health facility. Care may be provided in a general acute care Hospital
for all ages who meet the Plan's medical necessity criteria Should an Enrollee
require partial hospitalization, this service will be covered under this clause
with two (2) days of partial hospitalization equaling one (1) full day of inpatient
care. Contractor determines medical necessity and the appropriate facility for
treatment." New Hampshire General Service Agreement, Exhibit A.3,
page 4.
"Covered Services
G. Mental Health (MH) and Substance Abuse (SA)
1. Prevention/Education/Early
Intervention
a. Systematic Early Identification and Intervention for MH and
SA services: MH and SA problems shall be systematically identified and addressed
by the Enrollee's PCP at the earliest possible time following initial participation
of the Enrollees in the Plan or after the onset of a condition requiring MH
and SA treatment. PCPs and other Providers shall utilize mental health screening
tools and other mechanisms to facilitate early identification of MH and SA needs
for treatment.
b. MH and SA Education and Wellness: the Contractor shall offer
MH and SA prevention and education programs responsive to specific community
issues or Enrollee needs. Examples include:
1. teen mother substance abuse prevention program;
2. violence prevention programs; and
3. identification of symptoms of MH and 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 Service 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
BENEFITS PACKAGE-INCLUSIONS AND EXCLUSIONS
MEDICAID AND NJ KID CARE - PLANS A, B AND C
The health care services listed below shall be provided by the contractor
to enrollee as covered benefits under this contract. Provision of these
services shall be equal in amount, duration and scope as established by the
Medicaid program, in accordance with medical necessity without any predetermined
limits, unless specifically stated, and as set forth in the Medicaid Provider
Manuals: The New Jersey Administrative Code, Title 10, Department of Human
Services --Subtitle I--Division of Medical Assistance and Health Services; Medicaid
Alerts; and Medicaid Newsletters...
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.
- Substance abuse services--diagnosis, treatment, and detoxification
- Costs for Methadone and its administration
- Mental Health services
Those diagnoses which are
categorized as altering the mental status of an individual but are of organic
origin will continue to be part of the contractor's medical, financial and case
management r responsibilities. These include the diagnoses in the
following ICD-9-CM series:
293 - Transient organic psychotic conditions
294 - Other organic psychotic conditions (chronic)
308 - Acute reaction to stress
310 - Specific non-psychotic mental disorders due to organic
brain damage
315 - Specific delays in development
316 - Psychic factors associated with diseases classified elsewhere
317-319 - Mental Retardation
* The contractor shall be financially and medically liable for inpatient and ambulatory care of individuals whose primary diagnosis is not for mental health or substance abuse services...
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.
- Services provided in an inpatient psychiatric institution, that is not
an acute care hospital, to individuals under 65 years of age and over 21 years
of age." New Jersey Contract, Appendix A, pages 169-171.
“APPENDIX S
NJ KIDCARE - PLAN D
BENEFITS PACKAGE-INCLUSIONS AND EXCLUSIONS...
BEHAVIORAL HEALTH FEE-FOR-SERVICE
BENEFITS
1. Inpatient hospital services, including psychiatric hospitals, limited
to 35 days per year
2. Outpatient benefits for short-term, outpatient evaluative and crisis
intervention, or home health mental health services, limited to 20 visits per
year...
3. Inpatient and outpatient services for substance abuse are limited to
detoxification…" New Jersey Contract, Appendix S, pages 233-236.
"2.D.29 Behavioral
Health Services Included in the Benefit Package for Adults and Children:
2.D.29.a Inpatient Hospital Services...
2.D.29.b Hospital Outpatient Services...
2.D.29c Outpatient Health Care Professional Services..." New
Mexico Contract, page 42.
"10. Benefit Package,
Covered and Non-Covered Services...
10.8 Welfare Reform...
c) The Contractor is not responsible for the provision and payment of
alcohol and substance abuse treatment services mandated by the LDSS for Enrollees
as a condition of eligibility for Public Assistance or Medicaid. Public
Assistance or Medicaid recipients who are mandated into alcohol and substance
abuse treatment will be identified by the LDSS by the use of Welfare Reform
Exception Code 83 except:
i) The Contractor will continue to be responsible for a base Benefit Package
of Alcohol and Substance Abuse Services (ASA) and for the provision and payment
of ASA services to Enrollees when such treatment is underway and the LDSS is
satisfied with the health care and treatment plan….
(iv) The Contractor will continue to be responsible for Alcohol and Substance
Abuse Services specified in Section 10.16(a) of this Agreement.
(v) The Contractor will continue to be responsible for Alcohol and Substance
Abuse Services specified in Section 10.24 of this Agreement…" New
York Contract, pages 10-1-10-4.
"APPENDIX K-1
MANAGED CARE PLAN PREPAID BENEFIT PACKAGE...
Covered Services
Mental Health Services
Alcohol and Substance Abuse Services (ASA)
Managed Care Plan Scope
of Benefit
Covered when medically necessary, in accordance with the stop-loss provisions
as described in Section 3 of this Agreement. Enrollees must be allowed to self
refer for one mental health assessment from a Contractor's Participating Provider
in a twelve (12) month period. In the case of children, such self referrals
may originate at the request of a school guidance counselor or similar source.
Covered when medically necessary in accordance with the stop-loss provisions as described in Section 3 of this Agreement. Enrollees must be allowed to self refer for one (1) assessment from a Contractor's Participating Provider in a 12 month period.
Covered by MA Fee for Service...
Covered for all services in excess of 20 outpatient visits and 30 inpatient
days (combined mental health and substance abuse) in accordance with the
stop-loss provisions in Section 3 of this Agreement. Contractor continues to
reimburse mental health service providers and coordinate care. The Contractor
is reimbursed for payment through the stop-loss provisions.
Covered for all services in excess of sixty (60) outpatient visits and thirty
(30) inpatient days (combined mental health and substance abuse) in accordance
with the stop-loss provisions in Section 3 of this Agreement . Contractor
continues to reimburse ASA service providers and coordinate care. The
Contractor is reimbursed for payment through the stop-loss provisions.
Services ordered by the LDSS due to Welfare Reform (as indicated by 'code 83')…"
New York Contract, Appendix K, pages K-5-K-8.
"Appendix III
Schedule of Benefits
Out-of-Plan Benefits...
* Mental Health and Substance Abuse
* Mental Health - Inpatient & Outpatient..." North
Carolina Contract, Appendix III.
"2.2 Provision of
Covered Services...
(13) The Contractor must assure compliance with… mental health requirements
described in 42 USC 1396u-2 (b) (8)." North Dakota Contract, Attachment
C, pages 8-10.
"ATTACHMENT L:
COVERED SERVICES...
13. Mental Health Services - includes (1) inpatient psychiatric services
provided in the distinct parts unit of acute care hospitals, (2) institutions
for mental diseases including the State Hospital for individuals under 22 years
of age, (3) partial hospitalization, (4) outpatient hospital psychiatric care,
(5) The full range of therapy and rehabilitative services provided by the state
operated Regional Human Service Centers, (6) psychologist services, (7) outpatient
chemical dependency treatment, and (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 are responsible for ensuring that enrollees receive any medically
necessary mental health services and for coordinating those services with all
other medical and support services… MCPs, as a part of the benefit package,
are responsible for ensuring that enrollees receive psychiatric hospitalizations
in general hospitals, physician/psychiatrist services, psychology services,
general hospital psychiatric outpatient services, and outpatient clinic services.
2. Substance Abuse
Services
MCPs are responsible for ensuring that enrollees receive any medically-necessary
substance abuse services and for coordinating those services with all other
medical and support services. MCPs are responsible for ensuring that enrollees
receive medically necessary inpatient detoxification services, general hospital
outpatient alcohol and other drug treatment services, physician/psychiatrist
alcohol and other drug treatment services, psychology alcohol and other drug
treatment services, and outpatient clinic alcohol and other drug treatment services."
Ohio RFP, pages 13.
"APPENDIX A
BASIC BENEFIT PACKAGE BY SERVICE TYPE
The following types of services must be provided to covered persons by participating
health plans and at least to the extent such services are covered by Ohio Medicaid.
Additional covered services required under this contract are outlined in the
RFP...
26. Behavioral health services (see attached chart for more information)…"
Ohio RFP, Appendix A, pages 1-2.
"H. Coordination
with Out-of-Plan Services...
9. Behavioral Health Services
a. General
No mental health or drug or alcohol service, except pharmacy and ER services,
will be covered by the HealthChoices HMOs…" Pennsylvania RFP, pages
51-56.
"D. Tasks
1. In-Plan Services
The program includes medically necessary mental health and substance
abuse services…" Pennsylvania Behavioral Health RFP, page 48.
"2.06.02.01 General...
The comprehensive benefit package includes… mental health and substance abuse
services…" Rhode Island RFP, page 21.
"SCHEDULE OF IN-PLAN
BENEFITS...
Mental Health and Substance Abuse Services- Outpatient
Both short an long term treatment covered as needed based on medical necessity,
subject to stop-loss limitations in Definition Section 1.30 and groups/services
out-of-plan in Attachment B. Includes methadone detoxification collateral
visits, and medically necessary court-ordered services subject to limitations
described in Attachment B.
Mental Health and Substance
Abuse Services- Inpatient
Both short and long term treatment covered as needed, base on medical necessity.
(Butler Hospital may be used for services). Includes day treatment, partial
hospitalization, and residential treatment, except for residential treatment
for children ordered by DCYF, and except for residential substance abuse treatment
for children age 13 to 17. Covered residential treatment includes therapeutic
services but does not include room and board, except in a facility accredited
by the Joint Commission on accreditation of Healthcare Organizations ("JCAHO").
Covered services subject to limitations described in attachment B…"
Rhode Island RFP, Attachment A. pages 1, 3.
"CORE BENEFITS FOR THE
SOUTH CAROLINA MEDICAID HMO PROGRAM...
OUTPATIENT SERVICES
Outpatient services are defined as those preventive, diagnostic, therapeutic,
rehabilitative, surgical, and emergency services received by a patient
through an outpatient/ambulatory care facility…Included in these services are
treatments for mental health and substance abuse…" South Carolina
Contract, Appendix C, Tab 1, page 1.
"4.1 Core Benefits
For The South Carolina Medicaid HMO Program
Core benefits must be available to each Medicaid HMO Program member within the
Contractor's service area and the Contractor must provide a mechanism to reduce
inappropriate and duplicative use of health care services...
A summary listing of the
core benefits is as follows: ...
Mental Health and Alcohol and Other Drug Assessment Services…" South
Carolina Contract, Amendment 3, page 15.
"4.7.7 Mental
Health and Alcohol And Other Drug Abuse Assessment
The contractor is required to only provide mental health and alcohol
and other drug assessment services as specified in Appendix C, Tab 1.
All other mental health and alcohol and other drug services will be reimbursed
by SCDHHS on a fee-for-service basis. The Contractor must coordinate the
referral of Medicaid HMO Program members to enrolled Medicaid providers for
services that will be reimbursed fee-for-service." South Carolina
Contract, pages 20-21.
"MENTAL HEALTH ALCOHOL
AND OTHER DRUG ABUSE ASSESSMENT SERVICES
The Contractor is required to pay mental health and alcohol and other
drug abuse assessment services as follows:
90801 Psychiatric
Diagnostic Interview Exam
Psychiatric interview examination includes history, mental status, or
disposition. The physician elicits a complete medical and psychiatric
history (from the a patient and/or his family), establishes a tentative diagnosis
of the patient and evaluates the patient's capacity to work psychotherapeutically.
90802 Interactive
Psychiatric Interview Examination With Other Mechanisms of Communication
Interactive psychiatric diagnostic interview examination is typically
furnished to children. It involves the use of physical aids and non-verbal
communication to overcome barriers to therapeutic interaction between the clinician
and a patient who has not yet developed, or has lost, either the expressive
language communication skills to explain his/her symptoms and response to treatment,
or the receptive communication skills to understand the clinician if he/she
were to use ordinary adult language for communication.
W0051 Alcohol
and Drug Screen by Medical Doctor/Nurse Practitioner to Determine treatment
Needs
A physical examination is a fact-to-face interaction between a qualified
professional and the client to assess the client's status, provide diagnostic
evaluation and screening, and provide referral for AOD rehabilitative services.
The physical examination must also include a tuberculosis test, unless, justification
for omission of the test is documented on the physical examination form.
The physical examination is a component of the process to establish medical
necessity for the provision of AOD treatment services.
S8047 Physical
Examination - Department of Alcohol and Other Drug Abuse Services
A physical examination is a face-to-face interaction between a qualified
professional and the client o assess the client's status provide diagnostic
evaluation and screening, and provide referral for AOD rehabilitative services.
The Physical examination must also include a tuberculosis test, unless, justification
for omission of the test is documented on the physical examination form.
The physical examination is a component of the process to establish medical
necessity for the provision of AOD treatment services." South Carolina
Contract, Appendix C, Tab 1, pages 6-7.
"SECTION 2 - CONTRACTOR
RESPONSIBILITIES...
2-2. CONTRACTOR Qualifications
The CONTRACTOR shall comply with the following requirements at the inception
of this Agreement and at all times during the life of this Agreement: ...
Comprehensive health care
services shall include, but not be limited to:
8. mental health services, as currently required by the existing
Agreement and only until such time as the Partner’s Program is implemented…"
Tennessee Contract, pages 3-4.
"2-3. Benefit/Services
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:
o Psychiatric Inpatient Facility Services;
o Physician Psychiatric Inpatient Services;
o Outpatient Mental Health Services;
o Inpatient and Outpatient Substance Abuse Treatment Services;
o Psychiatric Pharmacy Services and Pharmacy Related Lab Services;
o Transportation to Covered Mental Health Services;
o Mental Health Case Management;
o 24-Hour Residential Treatment;
o Housing/Residential Care;
o Specialized Outpatient and Symptom Management;
o Specialized Crisis Services; and
o Psychiatric Rehabilitation Services.
This carve out of mental health and substance abuse services shall not relieve the CONTRACTOR from the responsibility to assist in the coordination of mental health and medical care of enrollees…" Tennessee Contract, pages 7-16.
"2-3.
Benefits/Service Requirements and Limitations
a. Covered Services
Effective upon implementation of the TennCare Partners Program, the responsibility for the provision and payment of mental health and substance abuse services shall be that of the Behavioral Health Organizations (BHOs). However, the 'carve out' of mental health and substance abuse services shall not relieve the CONTRACTOR from the responsibility to assist the BHOs in the coordination of mental health and medical care, case management and continuity of care of enrollees…" Tennessee Contract, pages 7-11.
"6.6 BEHAVIORAL HEALTH
CARE SERVICES - SPECIFIC REQUIREMENTS
6.6.1 HMO must provide or arrange to have provided to Members all behavioral
health care services included as covered services. These services are
described in detail in the Texas Medicaid Provider Procedures Manual (Provider
Procedures Manual) and the Texas Medicaid Bulletins, which is the bi-monthly
update to the Provider Procedures Manual…" Texas Contract, page 38.
"8. Mental Health
Services
When an Enrollee presents with a possible mental health condition to
his or her CONTRACTOR primary care physician, it is the responsibility of the
primary care provider to determine whether the Enrollee should be referred to
a psychologist, pediatric specialist, psychiatrist, neurologist, or other specialist.
Mental health conditions may be handled by the CONTRACTOR primary care provider
and referred to the Enrollee's Prepaid Mental Health Plan when more specialized
services are required for the Enrollee. CONTRACTOR primary care providers
may seek consultation from the Prepaid Mental Health Plan when the primary care
provider care provider chooses to manage the Enrollee's symptoms..."
Utah Contract, Attachment B, page 22.
"c. Non-covered
Services
1) Psychological evaluations and testing including neuropsychological
evaluations and testing for adult Enrollees is not the responsibility of the
CONTRACTOR...
d. Responsibility
of the Prepaid Mental Health Plan
The Prepaid Mental Health Plan is responsible for needed mental health
services to individuals with an organic and psychiatric diagnosis or with a
developmental and a psychiatric diagnosis." Utah Contract, Attachment
B, page 23.
"16. Treatment
for Substance Abuse and Dependency
Treatment will cover medical detoxification for alcohol or substance
abuse conditions. Medical services including hospital services will be
provided for the medical non-psychiatric aspects of the conditions of alcohol/drug
abuse." Utah Contract, Attachment C, page 4.
"Clarification of Non-covered
Services...
6. Inpatient and outpatient mental health services for substance
abuse disorders are not Covered services under the Contract." Utah
Mental Health Contract, page 7.
"20. Outpatient Mental
Health Services
The Contractor is responsible for covering outpatient mental health services
as set forth in 12 VAC 30-50-226 through 228.
21. Outpatient Substance
Abuse Treatment Services (CMSIP only)
The Contractor shall cover group and individual counseling with a limitation
of up to 26 sessions annually. If medically necessary, additional sessions
may be pre-authorized. Services must be rendered by a certified or licensed
provider. Day treatment for pregnant women is also covered but limited
to one course of treatment in a lifetime." Virginia Contract, page
49.
"33. Medallion
II Carved-Out Services
(a) The Contractor is not required to cover Medallion II carved-out services...
(b) The following services are Medallion II carved-out services:
(1) Community rehabilitation mental health services, mental retardation
services, and substance abuse treatment services… for Medicaid enrollees.
For CMSIP enrollees substance abuse treatment services are NOT carved out...
c… However, in no event is the Contractor responsible for the provision of the
following services, which will be reimbursed by the Department:
(1) Services for recipients with mental retardation and related conditions,
including case management, who are participants in the HCBS waivers are carved
out as set forth in 12 VAC 30-50-450 and 12 VAC 30-120-410, et seq.
(2) Inpatient mental health services rendered in a State psychiatric hospital…"
Virginia Contract, pages 55-56.
"COVERED SERVICES...
Inpatient Services: … Inpatient services provided by state mental hospitals
(licensed under chapter 70.05 RCW) and psychiatric hospitals (licensed under
chapter 71.12 RCW) are not included." Washington Contract, Exhibit
6, Attachment 1, page 1.
"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
--Inpatient Detoxification services for alcohol (3-day) and drugs (5-day) with
no complicating medical conditions...
--Mental health services purchased for all Medicaid clients by the Mental Health
Division in DSHS, including 24 hour crisis intervention, outpatient mental health
treatment services, and inpatient psychiatric services. This shall not
be construed to prevent contractors from purchasing covered outpatient mental
health services from community mental health providers…" Washington
Contract, Exhibit 6, Attachment 1, page 5.
"MCP Covered Services
The following charts presents an explanation of the medical services which the
MCP is required to provide...
The MCP must promptly provide or arrange to make available for enrollees all
medically necessary services listed below and assume financial responsibility
for the provision of these services...
MEDICAL SERVICES/ SCOPE
OF BENEFITS/ LIMITATION ON SERVICES
Behavioral Health Services for Children under Three/ Services for children with
handicapping conditions of children at rescue for developmental delays due to
biological, established or environmental factors. Level of intensity and
settings determined by family and professionals./ Behavioral health services
exclude services of psychiatrists and psychologists." West Virginia
RFA, Appendix A, page A1.
"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/ SCOPE
OF BENEFITS/ LIMITATION ON SERVICES
Behavioral Health Outpatient Services/ Diagnosis, evaluation, therapies, and
other program services for individuals with mental illness, mental retardation,
and substance abuse./ Procedure specific limits on frequency and units.
MEDICAL SERVICE/ SCOPE
OF BENEFITS/ LIMITATION ON SERVICES
Inpatient Psychiatric Services for individuals Under Age 21/ Active treatment
of psychiatric condition through an individual plan of care including post discharge
plans for aftercare. Service is expected to improve the recipients condition
of prevent regression so the service will no longer be needed./ Certification
must be made prior to admonition that outpatient behavioral health resources
available in the community did not meet the treatment needs of the recipient.
Pre-admission and continued stay prior authorization.
MEDICAL SERVICE/ SCOPE
OF BENEFITS/ LIMITATION ON SERVICES
Personal Care/ 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.
MEDICAL SERVICE/ SCOPE
OF BENEFITS/ LIMITATION ON SERVICES
Psychological Services/ Evaluation and treatment, including individual, family,
and group therapies./ Prior authorization is required for services beyond ten.
Evaluation and testing processes have frequency restriction." West
Virginia RFA, Appendix A, page A7.
"2.1.3 Medicaid
Benefits Covered But Excluded...
2.1.3.2 Behavioral Health
Prior to April 1996, virtually all behavioral health services will be provided
on a fee-for-service basis. Beginning in or after April 1996, a behavioral health
managed care organization (MCO) will provide these services on a capitated basis...
The behavioral health MCO
will be responsible for administering and reimbursing a network of providers
for the delivery of inpatient and outpatient behavioral health services for
Medicaid recipients, including those enrolled in MCPs. Behavioral health services
include, but are not limited to, the services listed below...
* evaluation, treatment planning and services coordination
* inpatient hospital care for psychiatric conditions
* 24 hour crisis services including an 800 number hotline available to
all consumers
* psychiatric physician services
* psychologist and social worker services supported living services
* State psychiatric hospital services
* case management services
* medication management
* transportation services
* residential long-term care for mental retardation/developmental disability
(MR/DD)
* rehabilitation/habilitation services...
Notwithstanding the role of the behavioral health provider, PCPs in the MCP should practice to the full level of their professional competency in the area of behavioral health. Behavioral health services provided by the PCP could include treatment for anxiety and other affective disorders including mild to moderate depression, psychosis, dementia and delirium. In these cases, the PCP will authorize treatment...
If a PCP is unable to manage a case, then the PCP would make a referral to the behavioral health provider and serve as the MCP's point of contact with the behavioral health provider. Similarly, the MCP will refer EPSDT cases to the behavioral health provider if the need for behavioral health intervention exists…" West Virginia RFA, pages 11-12.
"ADDENDUM II
POLICY GUIDELINES FOR MENTAL HEALTH/SUBSTANCE ABUSE AND COMMUNITY
HUMAN SERVICE PROGRAMS...
1. CONDITIONS ON COVERAGE
OF MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT FOR DISABLED PERSONS - On the effective
date of this Contract, unless waived by DHFS, the HMO shall, in compliance with
the provision of s. 632.89 Wis. Stats.:
a. be certified as an outpatient Mental Health and/or Substance Abuse
treatment facility; or
b. have contracted with a certified facility or other certified providers
under s. 632.89, Wis. Stats., for the treatment of mental health/substance abuse
problems.
Regardless of whether a. or b., above, is chosen, such treatment facilities and/or providers must provide transitional treatment arrangements in addition to other outpatient mental health and/or substance abuse services; such transitional treatment arrangements are defined as Adult Mental Health Day Treatment, Child/Adolescent Mental Health Day Treatment and Substance Abuse Day Treatment...
In compliance with said provisions, the HMO shall further guarantee all enrolled Medicaid recipients access to all medically necessary outpatient mental health/substance abuse treatment. No limit may be placed on the number of hours of outpatient treatment which the HMO shall provide or reimburse where it has been determined that treatment for mental disorders and substance abuse is medically necessary. The HMO shall not establish any monetary limit or limit on the number of days of inpatient hospital treatment where it has been determined that this treatment is medically necessary." Wisconsin Contract, Addendum II, page 79.