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SB 58 Behavioral Health Carve In Page 1

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SB 58 Behavioral Health Carve In

Page 1

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

Page 2

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

Page 3

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

Page 4

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

Page 5

Mental Health Rehab Service Codes

Page 6

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

Page 7

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

Page 8

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

Page 9

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

Page 10

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

Page 11

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.

Page 12

• 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.

Page 13

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

Page 14

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)

Page 15

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

Page 16

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)

Page 17