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9/15/2009 1 HealthChoices Behavioral Health Contract Changes Children in Substitute Care (CISC) Placed Out of Zone (OOZ)

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Presentation on theme: "9/15/2009 1 HealthChoices Behavioral Health Contract Changes Children in Substitute Care (CISC) Placed Out of Zone (OOZ)"— Presentation transcript:

1 9/15/ HealthChoices Behavioral Health Contract Changes Children in Substitute Care (CISC) Placed Out of Zone (OOZ)

2 9/15/2009 2

3 3 Prior to August 1, 2009…D&A OOZ Youth offended - appeared before the Judge Judge ordered placement in a D&A residential non-hospital program Court ordered where youth is placed Youth remained until order was satisfied Juvenile Justice system paid No coordination of care with BH-MCO

4 9/15/ After August 1, 2009…D&A OOZ Youth Offends and goes before the Judge Judge orders drug and alcohol assessment ASAM Criteria affirms need for D&A non- hospital residential rehab BH-MCO contacted and reviews for medical necessity – placement options offered at network provider or requested provider is approved

5 9/15/ After August 1 st contd. - BH-MCO Care Managers conduct periodic review of ongoing medical necessity Youth remains in treatment until criteria is no longer met or until court orders release BH-MCO pays while medically necessary C&Y can pay if no longer med necessay After-care is coordinated through the BH- MCO

6 9/15/ What is Potentially Different ? Drug and alcohol assessment completed prior to placement BH-MCO is contacted prior to placement Youth is placed in a D&A treatment bed BH-MCO pays for the treatment episode – can include room & board BH-MCO arranges for after-care upon return home

7 9/15/ Key Considerations Inserting the BH-MCO in the process Interface with New BH-MCOs Use of the ASAM Criteria Need to have youth in licensed D&A treatment beds Providers may need to enroll in PROMISE Rates are set by the BH-MCOs

8 9/15/ Prior to August 1 st – CISC OOZ Dependent child is placed out of their HealthChoices Zone Child remains or reverts to MA – FFS Accesses BH services directly TSS and RTF prior authorized through OMHSAS Medical Assistance Prior Auth Unit BH-MCO not responsible for coordination of care

9 9/15/ After August 1 st – CISC OOZ Dependent child is placed outside of zone Child remains in, or is enrolled in, the BH- MCO of original residence BH-MCO to be contacted for review of medical necessity (Appendix T)/auth of service Provider enrolls in BH-MCO’s network or is authorized as out-of-network provider

10 9/15/ What is Potentially different? Service authorization must be requested of BH- MCO of child’s residence BH-MCOs may have different policies, procedures and rates All apply Medical Necessity Criteria found in Appendix T BH-MCOs pay for services authorized Care is coordinated by BH-MCO upon child’s return

11 9/15/ Key Considerations - Additional services may be available in HC Physical Health coverage is not impacted HealthChoices rates are often higher than FFS Providers must be enrolled in MA and credentialed to be in BH-MCO networks

12 9/15/ Which issues do not change? Children in Detention Centers more than 35 days – Children in detention centers more than 35 days will continue as FFS. Authorizations requested while the child is in detention will be conducted by OMHSAS UR. – If the child is placed before an authorization is requested, the BHMCO will need to review for medical necessity before payment can be made.


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