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OMHSAS HealthChoices Behavioral Health Program PCCYFS Children’s Services Policy Day October 19, 2010.

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Presentation on theme: "OMHSAS HealthChoices Behavioral Health Program PCCYFS Children’s Services Policy Day October 19, 2010."— Presentation transcript:

1 OMHSAS HealthChoices Behavioral Health Program PCCYFS Children’s Services Policy Day October 19, 2010

2 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. 2

3 HealthChoices Oversight Secretary OMHSAS Deputy Secretary OMAP HealthChoices Steering Committee Operations Children’s Bureau Policy Quality Improvement & Medical Director Fiscal MIS Executive Committee Joint Management 3

4 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 4

5 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 5

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7 Contractual Requirements Programmatic: Access to Services Ongoing Review of Required Services Complaints and Grievance Processes 7

8 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

9 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 9

10 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 10

11 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 11

12 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 12

13 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. 13

14 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 14

15 Questions & Discussion 15

16 Contact Information Julie Barley- Acting Director for Eastern Operations- Valerie Vicari- Director for Western Operations- Stan Mrozowski- Director, Children’s Bureau- Scott Talley- Chief of Operations & Service Delivery, Children’s Bureau- 16

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