behavioral health carve-in - texas council healthcare... · 2016-09-22 · behavioral health carve...
TRANSCRIPT
Behavioral Health Integration Advisory Committee
• Established by the Senate Bill 58 of the 83rd Legislative
Session
• Tasked with providing formal recommendations to HHSC
by September 2014
• The inclusion of mental health targeted case management and
mental health rehabilitative services in Medicaid managed care
• The integration of behavioral and physical health services within
managed care
• The selection of two health home pilots programs in two health
service areas of the State
• Expires September 1, 2017
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Behavioral Health Carve In
• Effective September 1, 2014
• Targeted case management and mental health
rehabilitative services will be included in the managed
care benefit package
• The NorthSTAR service area will continue to
receive targeted case management and mental
health rehabilitative services through the
NorthSTAR delivery model
• NorthSTAR service area:
• Dallas, Ellis, Collin, Hunt, Navarro, Rockwall and Kaufman
counties
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Eligible Populations
• Mental health rehabilitative services and mental
health targeted case management are available to
Medicaid recipients who are assessed and
determined to have:
• A severe and persistent mental illness such as
schizophrenia, major depression, bipolar disorder or a
other severely disabling mental disorder
• Children and adolescents ages 3 through 17 years with
a diagnosis of a mental illness or who exhibit a serious
emotional disturbance
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Future Managed Care Services
• Targeted Case Management
• Must be face to face
• Include regular, but at least annual, monitoring of service effectiveness
• Proactive crisis planning and management for individuals
• Targeted case management is a Medicaid billable service provided separate from MCO service
coordination
• MCO must ensure that STAR Service Management units and STAR+PLUS Service Coordinators
coordinate with providers of TCM to ensure integration of behavioral and physical health needs of
Members.
• MCO must ensure that if a Member loses Medicaid eligibility, STAR Service Management units and
STAR+PLUS Service Coordinators refer the Member to Local Mental Health Authorities that can
provide indigent mental health care.
• Mental Health Rehabilitative Services include
• Crisis Intervention Services
• Medication Training and Support Services
• Psychosocial Rehabilitative Services
• Skills Training and Development Services
• Day Programs for Acute Needs
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Mental Health Rehab Service Codes
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Modifier Description
ET Emergency treatment
HA Child/adolescent program
HQ Group setting
TD RN
Day Program
Service Procedure Code
Modifier 1 Modifier 2 FFS Rate Unit
Adult Day Program for Acute Needs
G0177 $24.32 45-60 min
Mental Health Rehab Service Codes
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Medication Training and Support
Service Procedure
Code
Modifier 1 Modifier 2 FFS Rate Unit
Medication
Training and
Support
H0034 $13.53 15 min
Group services for
the adult
H0034 HQ $2.71 15 min
Individual services
for the child and
adolescent (with or
without other
individual)
H0034 HA $13.53 15 min
Group services for
the child and
adolescent (with or
without other
group)
H0034 HA HQ $3.38 15 min
Mental Health Rehab Service Codes
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Crisis Intervention
Service Procedure Code Modifier 1 Modifier 2 FFS Rate Unit
Adult services H2011 $36.89 15 min
Child and Adolescent
services
H2011 HA $36.89 15 min
Mental Health Rehab Service Codes
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Skills Training and Development
Service Procedure Code
Modifier 1 Modifier 2
FFS Rate
Unit
Individual services for adult
H2014 $25.02 15 min
Group services for adult
H2014 HQ $5.00 15 min
Individual services for the child and adolescent (with or without other individual)
H2014 HA $25.02 15 min
Group services for the child and adolescent
H2014 HA HQ $6.26 15 min
Mental Health Rehab Service Codes
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Psychosocial Rehabilitative Services
Service Procedure Code
Modifier 1 Modifier 2 FFS Rate Unit
Individual services
H2017 $26.93 15 min
Individual services rendered by an RN
H2017 TD $26.93 15 min
Group services H2017 HQ $5.39 15 min
Group services rendered by an RN
H2017 HQ TD $5.39 15 min
Individual crisis services
H2017 ET $26.93 15 min
Targeted Case Management Codes
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Service Procedure Code
Modifier Limitations FFS Rate
Unit
Routine mental health targeted case management (adult)
T1017 TF 32 units (8 hours) per calendar day for clients who are 18 years of age and older
$19.83 15 min
Routine case management (child and adolescent)
T1017 TF, HA, 32 units (8 hours) per calendar day for clients who are 17 years of age and younger
$24.07 15 min
Intensive case management (child and adolescent)
T1017 TG, HA, 32 units (8 hours) per calendar day for clients who are 17 years of age and younger
$31.69 15 min
Mental Health Rehab Service Codes
• The MCO is not responsible for providing Criminal Justice Agency funded
procedure codes with modifier HZ because these services are excluded from
the capitation.
• Crisis Intervention services are considered emergency behavioral health
services and do not require prior authorization but providers must follow
current RRUMG.
• Employment related services that provide training and supports that are not job
specific and have as their focus the development of skills to reduce or
overcome the symptoms of mental illness that interfere with the individual’s
ability to make vocational choices, attain or retain employment can be
provided under Skills Training and Development. These services should not
be confused with Employment Assistance or Supported Employment allowed
under the HCBS STAR+PLUS Waiver.
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• MCOs:
• Must cover mental health rehabilitative and mental health targeted case management services
effective September 1, 2014
• Required to utilize the current DSHS utilization management guidelines Texas Resilience and
Recovery (RRUMG) until September 2015
• RRUMG for Adult Mental Health Services can be found at Texas Resilience and Recovery Utilization
Management Guidelines - Adult Services (PDF)
• RRUMG Child and Adolescent Services can be found at Texas Resilience and Recovery Utilization
Management Guidelines- Child and Adolescent Services (PDF)
• RRUMG will be redesigned to better integrate physical health and behavioral health care services for
contract year 2015
• The MCO is not responsible for providing any services listed in the RRUMG that are not covered
• RRUMG service packages may include counseling, pharmacological management and other Medicaid
covered mental health services
• Maintain a qualified Network of entities, such as Local Mental Health Authorities (LMHAs) and
multi-specialty groups, that employ providers of MH Rehab Services and Targeted Case
Management.
• Provider entities must attest to the MCO that the organization has the ability to provide, either
directly or through sub-contract, Members with the full array of RRUMG services.
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MCO Responsibilities
• Adults Needs and Strengths Assessment (ANSA) and the Child and
Adolescent Needs and Strengths Assessment (CANS) will be leveraged in
managed care for consistency in assessment for services across the indigent
and Medicaid populations
• The MCO must ensure that providers use, and are trained and certified to
administer, the ANSA and CANS assessment tools to recommend a level of care to
MCO by using the current DSHS Clinical Management for Behavioral Health
Services (CMBHS) web based system
• Providers must have a signed user agreement with DSHS to complete assessment in CMBHS
• MCOs and providers may contact Dr. John Lyons at [email protected] for a coupon code to
receive online training on the administration of ANSA and CANS assessment tools
• The MCO must also ensure that providers complete the MH Rehab and TCM
Services Request Form and submit to MCO
• Level of Care information on form is tied to specific RRUMG service packages and hours
• Current authorizations are to be honored up to 90 days, to determine when re-
assessments for TCM and MH Rehab services must be completed, please refer to
RRUMG
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Assessments
Contracting with Provider Entities
• The MCO must credential Provider entities, and any licensed Network
Providers providing services through one of these entities, in accordance
with the Contract
• The MCO is not required to credential Providers of Mental Health
Rehabilitative Services and Targeted Case Management who are not
licensed providers types enrolled in Medicaid, such as a Peer Provider
(PP), Family Partner (FP), Community Services Specialist (CSSP), and
Qualified Mental Health Professional for Community Services (QMHP-
CS) if the QMHP is not also a Licensed Practitioner of the Healing Arts
(LPHA)
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Provider Qualifications and Supervisory Protocols
• Mental Health Rehabilitative Services Qualified Providers
• Qualified Mental Health Professionals for Community Services (QMHP-CS) the
requirement minimums for a QMHP-CS are as follow
Demonstrated competency in the work to be performed; and
Bachelor's degree from an accredited college or university with a minimum number of
hours that is equivalent to a major in psychology, social work, medicine, nursing,
rehabilitation, counseling, sociology, human growth and development, physician assistant,
gerontology, special education, educational psychology, early childhood education, or
early childhood intervention; or RN
An LPHA, as defined in Attachment A of the Contract, is automatically certified as a
QMHP-CS. A CSSP, a Peer Provider, and a Family Partner, as those terms are defined in
Attachment A of the Contract, can be a QMHP-CS if acting under the supervision of an
LPHA. If a QMHP-CS is clinically supervised by another QMHP-CS, the supervising
QMHP-CS must be clinically supervised by an LPHA
Additionally, a Peer Provider must be a certified peer specialist, and an Family Partner
must be a certified family partner
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Provider Qualifications and Supervisory Protocols
• Mental Health Targeted Case Management Qualified Providers
• A qualified provider of mental health targeted case management must:
• Demonstrate competency in the work performed; and
• Possess a bachelor's degree from an accredited college or university with a minimum
number of hours that is equivalent to a major in psychology, social work, medicine,
nursing, rehabilitation, counseling, sociology, human growth and development, physician
assistant, gerontology, special education, educational psychology, early childhood
education, or early childhood intervention; or
• Be a Registered Nurse (RN)
• MCO is prohibited from establishing additional supervisory protocols with
respect to the above-listed provider types
• MCO may not require the name of a performing provider on claims submitted
to the MCO if that provider is not a type that enrolls in Medicaid (such as
CSSPs, PPs, FPs, non-LPHA QMHPs, and Targeted Case Managers)
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