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What is a CMHSP? Community Mental Health Services Program.

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Presentation on theme: "What is a CMHSP? Community Mental Health Services Program."— Presentation transcript:

1 What is a CMHSP? Community Mental Health Services Program

2 A Governmental Entity Formed under Act 258 of the Public Acts of 1974 as amended (the Mental Health Code). 12 member boards appointed by County Commissions. For the Detroit Wayne County CMH Agency 6 members appointed by the Mayor, 6 appointed by the County Executive. At least one-third of the CMH Board must be consumers or family members. One half must be primary consumers. Subject to FOIA and Open Meetings Act. Duties include appointing Executive Director, an annual needs assessment & budget, evaluating the quality of services, establishing policy guidelines for operating the agency. Counties must contribute a financial match. CMHSP may be organized as an agency, organization or authority. This document prepared by: Michigan Association of CMH Boards 426 S. Walnut, Lansing, MI (517)

3 What Does a CMHSP Do? Carries out the contract between the state and the CMHSP. –Manages resources. –Responds to community needs and desires. –May provide services directly or manage a network of private providers. –Is the single point of entry for state psychiatric and developmental disability facilities. –Assures providers comply with standards of care –Assures protection of rights. –Accepts & resolves complaints, appeals and grievances. –Provides public benefit services, prevention & education. Serves approximately 250,000 persons annually –Not including persons served for addiction disorders. (60,000) MACMHB 2

4 How Are Services Paid For? The State contracts with the 46 CMHSPs. –There are two contracts: 18 Medicaid PIHP contracts total $1.9 billion. 46 state General Fund (GF) funding contracts total $322 million. FY10 Reduction of $40M, to be distributed disproportionately. –The Medicaid contract model is called a PIHP (Prepaid Inpatient Health Plan) PHIP areas must contain 20,000 Medicaid beneficiaries. 8 “free standing” CMHSPs are also PIHPs 10 regional affiliations have been organized by CMHSPs to meet the 20,000 requirement. –Each CMHSP has a GF contract for the indigent priority population. Waiting list depending upon $$ available. In FY09, ten (10) CMHSP had waiting lists. Anticipate more for FY10. Access to services based on severity of illness. –Substance abuse funding included only in the Medicaid contract. –The CMHSP pays claims to providers when it does not provide services directly within 90 days. State law defines “clean claim” and sets minimum time frames. –The State contracts with Substance Abuse Coordinating Agencies. –8 of 16 coordinating agencies are CMHSPs. MACMHB 3

5 What is Managed Care? In 1998, Medicaid Specialty Services (MI, DD, SUD programs) moved to a managed care model including capitated payments and financial risk for PIHPs. Arrangements that link healthcare financing & service delivery. –Allows the payer control over how & what services are provided & in Michigan we have combined this with Person Centered Planning to give the consumer more control. –Moving away from fee for service (the more visits the more fees) provides incentives is to keep people well, not sick. Incorporates many concepts. –Limiting choice of providers. –Gate keeping (authorization). –Risk Sharing (CMHSPs at 7.5% risk) & (State at risk for new eligibles). MACMHB 4

6 How Does a PIHP Work? PIHP (Prepaid Inpatient Health Plan) is a federal CMS designation. PIHPs are similar to Medicaid health plans/HMOs but not at full risk for funding & are not required to provide the full scope of medical services like an HMO. PIHPs are responsible for management of all specialty services to everyone enrolled in Medicaid. This is referred to as a “carve out” of specialty services. Medicaid health plans are responsible for a 20 visit per year benefit for persons with moderate psychiatric disabilities. Like HMOs, PIHPs can contract with providers, perform gate keeping and authorization, monitor service outcomes and standards of care. Like HMOs, PIHPs must manage with the capped pool of funds that are paid each month based on the number of Medicaid eligibles in the PIHP area. When eligibles go up or down, funding corresponds. The # of people seeking service does not necessarily correspond & therefore managing the utilization of services is critical. MACMHB 5

7 How Do People Access Services? All CMHSPs must have & advertise points of access within 30 minutes or 30 miles (rural exceptions) and 24 hour emergency service. When someone asks for help, a brief evaluation will result in a referral within 15 days for ongoing service. In emergent situations the person must be served within 3 hours. –People have a choice of provider. –People must sign a permission for treatment form. –People must complete the financial determination. –People denied service may have a second opinion. –People may file appeals at the local & state level. MACMHB 6

8 How Are Fees Determined? Ability to Pay (ATP) is based on State taxable income and a state mandated ATP process. –Evidence of taxable income is required. –The MH Code defines the parameters and establishes difference for Residential & State Facility Care. CMHSPs cannot bill people with Medicaid. Most other insurances, including Medicare are accepted. All information is confidential & people are required to sign releases so that insurances can be billed. People are not denied services because of an inability to pay, but may be refused service if they refuse to submit financial information or allow insurance companies to be billed. –Some insurances will not pay for public mental health care & the person may be required to pay the full amount unless they go to the place specified by their insurance. Unpaid fees may be turned over to collection agencies. People may appeal the established fee. MACMHB 7

9 What Are the Rules for Service Planning Care is provided based on a Person Centered Plan (PCP). Services are defined by the federal government and the state and may vary depending on the person’s eligibility. –People may have different benefit packages. The PIHP authorizes care in the PCP based upon researched criteria and evidence. – The amount, type, and duration of care necessary to achieve the outcome desired. Medicaid requires that CMHSPs use other available community resources “first.” –State policy also requires least restrictive care in integrated community environments maximizing community & natural supports before expenditure of State & Federal $$. MACMHB 8

10 What Services Are Provided? Crisis Service must be available 24/7. Inpatient Screening must be available 24/7. An array of other services may be provided. When an array is provided the person also has a “care manager” or “supports coordinator” to help plan, link the person to the services, and monitor the provision of care. –Inpatient, partial hospitalization, crisis residential, respite care, assertive community treatment, jail diversion, community living supports, personal care in residential setting, assessments, psychological testing, supported employment, medication management, psychiatric services, speech, physical and occupational therapies, behavior management, home-based services, wraparound services for children, clubhouse, and drop in centers are some examples of the services available. MACMHB 9

11 How Is The Quality of Services Assured? CMHSPs have built in systems of checks & balances. Many of them are required in the contract with the State and are monitored annually by MDCH & the Legislature. –Credentialing, standards and best practice guidelines –People served and costs, service category and cost. –MMBPIS – Michigan’s Mission Based Performance Indicator System measures (timeliness, supported employment, people served in their own homes, penetration rates, number of denials and second opinions, suicide rates, waiting lists and others). –Medicaid required external quality review. Other systems include: –National accreditation. –Other licensing such as DCIS, substance abuse. –Recipient rights. Review of critical incidents. –Mystery shopper programs. –Consumer and advisory council review of data. –Utilization management and peer review. MACMHB 10

12 What If CMHSP Budgets Are Cut? The overall State Economy Suffers – Medicaid is Good Medicine for State Economies. –In 2001 increased business activity as a result of Medicaid in Michigan was $8.9 billion. –In 2003 every million dollars invested will bring an average $3.4 million return in business activity. –People in the State become uninsured and delay or avoid timely care increasing indigent healthcare cost. One of five things can occur at the Local CMHSP level –Reduce administrative costs/ bureaucratic burden. –Reduce the amount of services given each individual. –Eliminate some services/ benefits. –Reduce the amount of time a service is provided. –Reduce the number of people eligible for given services. These reductions cause a spiraling effect so that only catastrophic, very expensive care can be provided. This document prepared by: Michigan Association of CMH Boards 426 S. Walnut, Lansing, MI (517)


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