new mega regs policy & procedure (p&p) approval … · new mega regs policy & procedure...

NEW MEGA REGS POLICY & PROCEDURE (P&P) APPROVAL REQUEST FORM

I. P&P INFORMATION

Assigned Policy Name:

Assigned Policy Number:

Mega Regs Policy Area(s): Mark All That Apply

☐ Plan Administration and Organization ☐ Provider Network

☐ Scope of Services ☐ Documentation Requirements

☐ Financial Reporting Requirements ☐ Coordination and Continuity of Care

☐ Management Information Systems ☐ Beneficiary Rights

☐ Quality Improvement System ☐ Beneficiary Problem Resolution

☐ Utilization Management Program ☐ Program Integrity

☐ Access and Availability of Services ☐ Reporting Requirements

Submitted by: Date:

Policy developed by: _________________________________________________________________________________________

Attach P&P Document For Review In this Section

II. APPROVAL

Section A: HHS Compliance and County Counsel

HHS Compliance: Date:

County Counsel: Date:

Review and Approval by BHSD Directors

Section B: BHSD Executive Director

BHSD Executive Director: Date:

Note - A copy of the Approved Mega Regs P&P Form will be emailed to: BHSD Compliance Unit

DocuSign Envelope ID: 5BCF32D2-6554-4FE6-9FC4-ECA6C5E3496B

X

Beneficiary Rights

11400

Victor Ibabao

Mary Harnish

3/29/2018

4/4/2018

4/11/2018

4/11/2018

Policy & Procedure Number: BHSD # 11400

x BHSD County Staff

x Contract Providers

x Specialty Mental Health

x Specialty Substance Use Treatment Services

Title: Beneficiary Rights

Page 1 of 11

Approved/Issue Date:

Behavioral Health Services Director:

Last Review/Revision Date:

Next Review Date: Inactive Date:

REFERENCE:

The Americans with Disabilities Act of 1990

28 CFR Part 35 Nondiscrimination on The Basis of Disability in State and Local Government Services §§35.101-Appendix C.

36 CFR Parts 1193 and 1194. Information and Communication Technology (ICT) Standards and Guidelines

42 CFR §438.3(d) Standard Contract Requirements

42 CFR §438.10 Information Requirements

42 CFR §438.100 Enrollee Rights and Protections

42 CFR §438.102 Provider-enrollee communications.

42 CFR §438.114 Emergency and Post Stabilization Services

42 CFR §§438.400 -§438.424 Grievance and Appeal System

42 CFR §§ 438.206-210 MCO, PIHP, PAHP Standards

45 CFR §164. Security and Privacy

42 CFR Part 2. Confidentiality of Substance Use Disorder Patient Records

2 CCR §§ 11135 - 11139.8. Discrimination

9 CCR § 1810.410. Cultural and Linguistic Requirements

9 CCR § 1810.360. Notification of Beneficiaries

9 CCR §§ 851-852 Informed Consent to Antipsychotic Medications and Maintenance of Records

WIC § 5325.1 Persons with Mental Illness Legal Rights and Responsibilities

412-014 Site Certification

412-313 Client Access to Records

412-319 Voter Registration

BHSD Policy #11300 Providing Language Services

BHSD Policy #12000 Beneficiary Problem Resolution Process

BHSD Policy #11100.1 Advance Directives

Santa Clara County Behavioral Health Services Department Cultural Competency Plan



x BHSD County Staff





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POLICY: The purpose of the policy is to outline beneficiary rights and the rights of other service recipients and describe the required activities to reinforce and support rights. BHSD and its provider network have mechanisms in place to protect and ensure beneficiary rights.

POLICY: DHCS defines beneficiary rights to include but not be limited to:

• Be treated with personal respect and respect for your dignity and privacy. • Receive information on available treatment options and alternatives; and have them

presented in a manner they can understand. • Participate in decisions regarding their mental health care, including the right to

refuse treatment. • Be free from any form of restraint or seclusion used as a means of coercion,

discipline, convenience, punishment or retaliation as specified in federal rules about the use of restraints and seclusion in facilities such as hospitals, nursing facilities and psychiatric residential treatment facilities where you stay overnight for treatment.

• Request and receive a copy of their medical records, and request that they be amended or corrected.

• Receive the information in this booklet about the services covered by the MHP, other obligations of the MCP and their rights as described here.

o The right to receive this information and other information provided to them by the MCP in a form that is easy to understand. This means, for example, that the MCP must make its written information available in the languages that are used by at least 5 percent or 3,000, whichever is less, of Medi-Cal eligible people in the MHP’s county and make oral interpreter services available free of charge for people who speak other languages.

o This also means that the MCP must provide different materials for people with special needs, such as people who are blind or have limited vision or people who have trouble reading.

• Receive specialty mental health services from a MCP that follow the requirements of its contract with the State in the areas of availability of services, assurances of adequate capacity and services, coordination and continuity of care, and coverage



x BHSD County Staff





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and authorization of services. For beneficiaries, BHSD is required to:

o Employ or have written contracts with enough providers to make sure that all beneficiaries who qualify for behavioral health services can receive them in a timely manner.

o Cover medically necessary services out-of-network for beneficiaries in a timely manner, if the MCP doesn’t have an employee or contract provider who can deliver the services. “Out-of-network provider” means a provider who is not on the MCP’s list of providers. The MCP must make sure beneficiaries do not pay anything extra for seeing an out-of-network provider.

o Make sure providers are qualified to deliver the specialty mental health services that the providers agreed to cover.

o Make sure that the specialty mental health services the MCP covers are adequate in amount, duration and scope to meet the needs of the beneficiaries it serves. This includes making sure the MCP’s system for authorizing payment for services is based on medical necessity and uses processes that ensure fair application of the medical necessity criteria.

o Ensure that its providers perform adequate assessments of individuals who may receive services and work with the individuals who will receive services to develop a treatment plan that includes the goals of treatment and the services that will be delivered.

o Provide for a second opinion from a qualified health care professional within the MHP’s network, or one outside the network, at no additional cost to the beneficiary.

o Coordinate the services it provides with services being provided to an individual through a managed care health plan or with your primary care provider, if necessary, and in the coordination process, to make sure the privacy of each individual receiving services is protected as specified in federal rules on the privacy of health information.

o Provide timely access to care, including making services available 24-hours a day, 7 days a week, when medically necessary to treat an emergency psychiatric condition or an urgent or crisis condition.

o Participate in the State’s efforts to promote the delivery of services in a culturally competent manner to all individuals, including those with limited English proficiency and diverse cultural and ethnic backgrounds.

o Must ensure the beneficiary’s treatment is not adversely affected as a result of them using their rights.



x BHSD County Staff





Page 4 of 11

DEFINITIONS: Advance Directive. Written instructions, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by courts of the State), relating to the provision of the healthcare when the individual in incapacitated. Appeal. A review by BHSD or Contract Agency of an adverse benefit determination. Assessment. A service activity designed to evaluate the current status of mental, emotional, or behavioral health. Assessment includes, but is not limited to, one or more of the following: mental status determination, analysis of the clinical history, analysis of relevant cultural issues and history; diagnosis; and the use of mental health testing procedures Beneficiary – A Medi-Cal recipient who is currently receiving services from BHSD or a BHSD contracted provider. Emergency. A Condition or situation in which an individual has a need for immediate medical attention, or where the potential for such need is perceived by emergency medical personnel or a public safety agency (Health & Safety Code § 1797.07). Grievance. An expression of dissatisfaction about any matter other than adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the beneficiary’s rights regardless of whether remedial action is requested. Grievance includes a beneficiary’s right to dispute an extension of time proposed by BHSD to make an authorization decision. (42 C.F.R. § 438.400) Provider. A person or entity who is licensed, certified, or otherwise recognized or authorized under state law governing the healing arts to provide specialty mental health services and who meets the standards for participation in the Medi-Cal program as described in California Code of Regulations, title 9, Division 1, Chapters 10 or 11 and in Division 3, Subdivision 1 of Title 22, beginning with Section 50000. Provider includes but is not limited to licensed mental health professionals, clinics, hospital outpatient departments, certified day treatment facilities, certified residential treatment facilities, skilled nursing facilities, psychiatric health facilities, general acute care hospitals, and acute psychiatric hospitals. The MHP is a provider when direct services are provided to beneficiaries by employees of the Mental Health Plan.



x BHSD County Staff





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PROCEDURE

Responsible Party

Action Required

BHSD Administration

1. Acquire and maintain written contracts with enough providers to

make sure that all enrollees and other service recipients who qualify for specialty mental health services can receive them in a timely manner.

2. Makes sure providers are qualified to deliver behavioral health services and that providers are in compliance with what services they agreed to cover.

3. Makes certain covered services are adequate in amount, duration and scope to meet the needs of the Medi-Cal eligible individuals it serves. This includes making sure the MCP’s system for authorizing payment for services is based on medical necessity and uses processes that ensure fair application of the medical necessity criteria.

4. Ensures that its providers perform adequate assessments of individuals who may receive services and work with the individuals who will receive services to develop a treatment plan that includes the goals of treatment and the services that will be delivered.

5. Does not prohibit informed consent or activities that promote the dignity of beneficiaries.

6. Provide for a second opinion from a qualified health care professional within the MCP’s network, or one outside the network, at no additional cost to the individual.

7. Coordinate the services it provides with services being provided to an individual, including their primary care provider. Ensures that the privacy of each individual receiving services is protected as specified in federal rules on the privacy of health information.

8. Provides timely access to care, including making services available 24-hours a day, 7 days a week, when medically necessary to treat an urgent or emergent behavioral health condition.

9. Participates in the State’s efforts to promote the delivery of services in a culturally competent manner to all individuals, including those with limited English proficiency and diverse cultural and ethnic backgrounds.



x BHSD County Staff





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10. Provides and requires provider workforce education, training and development related to cultural competency on an annual basis.

11. Ensures treatment is not adversely affected as a result of individuals using their rights.

12. Covers medically necessary services out-of- network in a timely manner, if the MCP doesn’t have an employee or contract provider who can deliver the services.

13. Ensures individuals don’t pay anything extra for seeing an out-of-network provider.

14. Provides language services and written materials free of charge to beneficiaries.

BHSD Quality Assurance Department

1. Conducts site certifications every 3 years for MCP entities to

determine if provider is in compliance with individual rights and regulations.

2. Materials developed and distributed by BHSD to be given to individuals will meet readability, font size and threshold language requirements in addition to being field tested in advance of distribution.

3. Reviews BHSD Beneficiary Handbook on an annual basis and makes changes as needed. The content of the handbook and any changes need to be consistent with State and Federal requirements. .

4. Updates and distributes the BHSD Beneficiary Handbook to all Medi-Cal beneficiaries and providers at least 30 days prior to a change.

5. In conjunction with the Business Office, updates Provider List when there is a change in scope of behavioral health services and on a monthly basis. The Provider List will include all required information in accordance with the State and Federal requirements .

6. Posts BHSD Beneficiary Handbook and Provider List on BHSD Website. https://www.sccgov.org/sites/bhd/Pages/home.aspx

7. Will update State Advance Directive changes within 90 days of implementation of the change.

a. Will notify providers of State changes. 8. Maintains TTY information about materials on the BHSD Website.

https://www.sccgov.org/sites/bhd/Pages/home.aspx 9. Will make a good faith effort to provide a written notice of


https://www.sccgov.org/sites/bhd/Pages/home.aspx

https://www.sccgov.org/sites/bhd/Pages/home.aspx


x BHSD County Staff





Page 7 of 11

termination of the contracted provider within 15 calendar days to each enrollee that had received services from or was seen on a regular basis by the terminated contract provider.

10. Process and monitor grievances, appeal, expedited appeals filed with BHSD.

11. Oversees Notices of Adverse Benefit Determinations to ensure providers cannot request enrollee disenrollment for:

a. Change in enrollee health status b. Utilization of medical services c. Diminished capacity d. Uncooperative or disruptive enrollee behavior secondary to

special needs. 12. Report performance data which includes but is not limited to:

a. Enrollment and disenrollment data b. Grievance and Appeal Logs c. Provider Compliant and Appeal Logs d. Timely Access Logs

Providers

1. Facilities meet American’s with Disability Act physical access and

reasonable accommodations requirements. 2. Has accessible equipment for beneficiaries with physical or mental

disabilities. 3. Provide each beneficiary with all BHSD notices and informational

materials in a manner and format that is easily understood. a. In regular and large font b. In Threshold Languages c. Use auxiliary aids such as TTY and American Sign

Language d. Make oral interpretation serviceavailable and provide those

services free of charge to each potential beneficiary and beneficary.

4. Makes available the BHSD Beneficiary Handbook and Provider List in all threshold languages.

5. Change out Guide to BHSD Beneficiary Handbook and Provider Lists within 30 days of BHSD notification of changes.

6. Displays County Grievance, Appeal and Expedited Appeal processes in all threshold languages in site waiting areas.



x BHSD County Staff





Page 8 of 11

7. Has pre-paid addressed envelopes, grievance, appeal and expedited appeal forms readily available in site waiting areas.

8. Ensures individuals receive Voter Registration services, maintains separate records that individuals served by the program have been offered the opportunity to register to vote per BHSD Voter Registration Policy #412-319.

9. Provide Advance Directive training regarding provider policies and procedures related to advance directives.

10. Provide Advance Directive information to individuals when they first receive services and on request.

11. Places Advance Directives in the client record and prominently note enrollee has an Advance Directive.

12. Participates in annual cultural competency trainings. 13. If a client requests a Second Opinion:

a. For mental health services, contact the Call Center at (800) 704-0900 to arrange a referral for a second opinion.

b. For substance use treatment, the provider or the beneficiary notifies the Beneficiary Line (408) 792-5666 to arrange a referral for a second opinion.

14. Prepares and tests any proposed written materials for readability, threshold languages and font size prior to distribution.

15. Measures and meets timely access standards. 16. Issues a formal valid termination notice 30 days prior to BHSD

contract termination, if applicable. a. If closing:

i. Submit beneficiary records to BHSD. ii. Arrange for electronic record access for BHSD.

17. Works with BHSD Contract Monitors to transition beneficiary care.

Clinical or Medical Staff

1. Provide informed consent discussion that covers:

a. Nature of client’s condition b. Type, range of frequency, amount (including PRNs),

method (oral or injection) and duration of taking medication. c. Reason for treatment or services, including the likelihood of

improving or not improving without such intervention. d. Probable side effects of any medications known to

commonly occur, any particular side effects likely to occur



x BHSD County Staff





Page 9 of 11

with the individual and other possible side effects of long-term usage.

e. The type and frequency of other recommended treatment interventions including but not limited to case management services, psychiatry appointments and group or individual therapy.

f. Reasonable alternative treatments, if any. g. The right to participate in decisions regarding their care. h. The right to refuse treatment. i. The right to withdraw consent at any time for any reason. j. The right to give written (signed) or oral consent to

treatment. 2. For second opinion requests:

a. For mental health, conduct assigned requests for a second opinion through a face to face evaluation within 30 days of referral.

b. For substance use treatment services, conducts a face to face assessment within 5 days of receipt of referral.

3. Assists in completion or links to entities that can complete Advance Directive on enrollee request.

4. Perform enrollee assessment for those who will receive services in order to develop a treatment plan with the enrollee that includes goals of treatment and services to be delivered.

a. Obtain signature of individual, individual’s legal representative or conservator or the individual’s parent or legal guardian for children and adolescents.

b. Document if the individual does not or cannot sign the plan in a progress note.

c. Provide individual/family with copies of the plan. 5. Update assessment and plan information when the individuals

condition changes, new needs emerge and when renewal is required due to documentation timelines.

6. Links enrollees to Long Term Support Services (LTSS) if they express a desire to receive LTSS or they appear to qualify for LTSS.



x BHSD County Staff





Page 10 of 11

Call Center

1. Maintains a toll-free number offering assistance to help

beneficiaries understand the managed care plan and can assist in making enrollment decisions.

2. Ask individuals with limited English proficiency (LEP), limited reading proficiency and those with other language and communication barriers their preferred language and refers individuals to a provider that can meet these communication needs.

3. Offer beneficiaries a choice of provider and change of provider.

BHSD Division Director or designee

1. Ensures appropriate written notice of termination is provided to the Department Director and Board of Supervisors.

2. Provides proper written notifications are provided to each affected beneficiary within 15 calendar days of notification of termination of a contracted provider.

BHSD Contract Monitor

1. Coordinates the transition of the beneficiary to an alternative program (if applicable).

2. Notifies the Call Center and other referring entities of the Program (or Agency) closure so that future referrals cease, referrals in progress are redirected to other programs.

3. Meet with the Contractor: a. Review the number of clients to be closed and/or

transferred. a. Utilize BHSD electronic record system to identify current

open caseload. b. Review the 30, 60, 90 day report to identify potential

case closures. 4. Help identify which programs or agencies in which to transition the

clients. 5. Facilitate transition meeting with BHSD contractors if needed. 6. Track transition progress made by BHSD contractors. 7. Secure any County equipment and inventory items belonging to

BHSD. 8. If the program and the agency is closing:

a. Identify is there are any paper charts.



x BHSD County Staff





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i. Paper charts belong to BHSD when a program and agency close. Charts will need to be stored at iron Mountain through BHSD.

c. Electronic records in agency’s HER will need to be collected by BHSD.

9. If only the program is closing but the BHSD contractor has a contract with BHSD:

a. BHSD contractor will maintain the client records and make them available to clients upon request within the timeframe designated for storage of records.

10. Ensure BHSD contractor has closed all cases in the relevant BHSD electronic records system after proper transition of the clients.

11. Submit a UCCAR to terminate the U-code once billing for services is completed (typically 3-6 months after termination).

Attachments:

A

Program Closure – Sample Notification Letter

B

Program Closure – Client Tracking Table


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