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OMHSAS HealthChoices Behavioral
Health Program
PCCYFS Children’s Services Policy Day
October 19, 2010
OMHSAS Vision Statement
Every person with serious mental illness and/or addictive disease, and every child and adolescent who abuses substances and/or has a serious emotional disturbance will have the opportunity for growth, recovery and inclusion in their community, have access to services and supports of their choice, and enjoy a quality of life that includes family and friends.
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HealthChoices Oversight Secretary
OMHSAS Deputy SecretaryOMAP
HealthChoices Steering Committee
OperationsChildren’s
BureauPolicy
Quality Improvement&
Medical Director
Fiscal
MIS
Executive Committee
Joint Management
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HC-BH Program Overview
Statewide Mandatory MA Managed Care Begin in 1996- implemented statewide in 2007 1915(b) CMS Waiver of Social Security Act
Available in 67 Pennsylvania Counties 2.1 million Medical Assistance eligible members Annual cost $2.8 billion 2010 Goals:
Improve Access to Care Improve Quality of Care Stabilize MA Spending
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HC-BH Program Structure
BH HealthChoices Separate Contract County Right of First Opportunity to bid on contract 34 total BH contracts – 32 with County Government DPW holds direct contract with BH-MCO for Greene County & 23
County North Central area OMHSAS Regional Field Office Contract Monitoring Team
BH –PH Coordination Meetings HealthChoices PH Contracts ACCESSPlus PH Contracts PH Voluntary Contracts
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Department of Public Welfare HealthChoices Behavioral Health Office of Mental Health and Substance Abuse Services Statewide Expansion Draft 3/9/06
Cambria VBH 21,515
Huntingdon 6,519 CCBHO
Blair CBHNP 21,983
Forest 656 CCBHO Venango
VBH 9,186
Mercer VBH 19,875
Lawrence VBH 15,305 Butler
VBH 16,576
Clarion 5,780 CCBHO
Crawford VBH 15,308
Erie VBH
52,063 Warren
5,322 CCBHO
Jefferson 7,781 CCBHO
Clearfield 14,265 CCBHO
Centre 10,002 CCBHO
McKean 7,408 CCBHO
Elk 4,402 CCBHO
Cameron 985 CCBHO
Potter 2,793 CCBHO
Northampton MBH 31,636
Lebanon CBHNP 15,647
Cumberland CBHNP 16,449
Perry CBHNP 4,523
Juniata 2,679
Mifflin 7,608 CCBHO Dauphin
CBHNP 37,631
Schuylkill 20,654 CCBHO
Montgomery MBH 58,478
Berks CCBHO 61,473
Bucks MBH 44,761
Lehigh MBH 50,561
Columbia 7,842
Montour 2,133 CCBHO
Snyder 4,187 CCBHO
Union 3,865 CCBHO
Northumberland 12,963 CCBHO
Lycoming CBHNP 16,888
Tioga 5,475 CCBHO
Sullivan 710 CCBHO
Bradford 9,457 CCBHO
Pike CCBHO 5,986
Carbon CCBHO 7,681
Luzerne CCBHO 50,587
Monroe CCBHO 22,615
Susquehanna CCBHO 5,688
Wyoming CCBHO 4,021
Wayne 6,620 CCBHO
HEALTHCHOICES BEHAVIORAL HEALTH ZONES
SOUTHWEST Implemented Jan. 1999
LEHIGH/ CAPITAL SOUTHEAST Implemented Feb. 1997 Implemented Oct. 2001
BH Implementation July 1, 2007 January 1, 2007
NORTH/ CENTRAL RIGHT OF FIRST OPPORTUNITY
BH Implementation NORTHEAST BH Implementation July 1, 2006
Lackawanna CCBHO 32,114
Adams CCBHO 8,355
York CCBHO 46,905
Lancaster CBHNP 56,734
Chester CCBHO 30,226
Philadelphia CBH 447,415
* Covered lives as of July 2010
Allegheny CCBHO 166,394
Beaver 24,735
Armstrong VBH 10,674
Indiana VBH 10,885
Westmoreland VBH 43,545
Washington VBH 25,302
Greene VBH 7,493
Fayette VBH 30,697
Bedford CBHNP 6,912
Clinton CBHNP 5,827
Franklin CBHNP 15,168
Fulton CBHNP 2,130
Somerset CBHNP 9,636
Department of Public Welfare Office of Mental Health and Substance Abuse July 22, 2010
Delaware MBH 68,349
SOUTHWEST Implemented Jan. 1999
NORTHEAST Implemented July 1, 2006
LEHIGH/ CAPITAL Implemented Oct. 2001
NORTH/ CENTRAL STATE OPTION BH Implementation Jan. 1, 2007
SOUTHEAST Implemented Feb. 1997
NORTH/ CENTRAL COUNTY OPTION BH Implementation July 1, 2007
Contractual Requirements
Programmatic:
Access to Services
Ongoing Review of Required Services
Complaints and Grievance Processes
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Contractual Requirements
Development of Services
Who decides to add a services?
When is the decision made?
Who pays for the new services?
What about room and board?
Provider Network & Credentialing 8
Contractual Requirements
Financial Claims Payment
Timely filing of Claims Clean Claims
Primary Contractor Shall adjudicate: 90% Clean Claims within 30 days 100% Clean Claims within 45 days 100% of all claims within 90 days
Timeliness for Reimbursement Third Party Liability
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Eligibility Requirements
Are there still different zones? Who is responsible for out-of-state placements? Who is responsible for checking eligibility? What happens when there is dropped eligibility? HIP/FFS Eligibility in Juvenile Detention Centers
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Timelines Standards For Authorization and Payment of Services
State Standards/Bulletins
OMHSAS- 10-04-Psychological/Psychiatric/Clinical Re-Evaluations and Re-Authorizations for BHRS
OMAP- 01-93-04- Payment for MH services Provided in a RTF for Eligible Individuals Under 21 Years of Age
OMAP- 1165-95-01- JCAHO Accredited Services
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Medical Necessity Criteria
Evaluation and documentation-Physician (Psychiatrist) or Licensed Psychologist
Severity of the illness present meets criteria for specific level of care/service.
Potential for person to benefit from this level of care. Most appropriate and least restrictive to meet MH needs. Continued Care Criteria- person continues to meet
criteria and benefit from service. Discharge/Referral Criteria
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Access to Service
The provider network must provide face-to-face treatment intervention within: One hour for emergencies Twenty-four hours for Urgent situations Seven days for routine appointments and for specialty
referrals. Upon initial face-to-face intervention, the
implementation of the treatment services must adhere to the prescribed treatment plan, including the start date and frequency of treatment services.
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Evidence Based Practices
MST, FFT, MTFC, PCIT Researched Based Over 75% Counties at least one EBP What do we need to know?
Must meet MA Requirements
Must maintain fidelity/certification to model
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Contact Information
Julie Barley- Acting Director for Eastern Operations- [email protected]
Valerie Vicari- Director for Western Operations- [email protected]
Stan Mrozowski- Director, Children’s Bureau- [email protected]
Scott Talley- Chief of Operations & Service Delivery, Children’s Bureau- [email protected]
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