1. Navigating the Public Behavioral Health System (PBHS)
MARYLAND DEPARTMENT OF HEALTH
Navigating the Public Behavioral Health System (PBHS)
Stacy Seymore, COTA/L, CPRP
Behavioral Health Administration

2. Learning Objectives
Participants will receive an overview of the Public Behavioral Health System (PBHS)
Participants will learn about the services offered for adults through the PBHS
Participants will learn about eligibility for and access to PBHS services

3. Behavioral Health Administration
The Maryland Department of Health’s Behavioral Health Administration (BHA) is the merged entity that was formerly the Mental Hygiene Administration and the Alcohol and Drug Abuse Administration.

4. BHA Mission
The BHA will, through publicly funded services and support, promote recovery, resiliency, health, and wellness for individuals who have or are at risk for emotional, substance related, addictive, and/or psychiatric disorders.

5. PBHS Administrative Entities
BHA
Core Service Agency (CSA)/Local Addiction Authority (LAA), and Local Behavioral Health Authority (LBHA)
Administrative Services Organization (ASO)

6. Role of BHA Oversees the PBHS: Policy development Statewide planning
Resource allocation
Continuous quality improvement

7. Role of the CSAs/LAAs/LBHAs
Manage the PBHS at the local level:
Assure individual access and consumer rights
Assess need; plan and develop services, resources, and local provider network; establish interagency coordination of care
Develop specialized services and monitor grant-funded services
Address local complaints, grievances, and appeals

8. CSA/LAA/LBHA Jurisdictions
Mid-Shore CSA: Caroline, Dorchester, Kent, Queen Anne’s, and Talbot Counties

9. Role of the ASO Beacon Health Options Maryland
Reviews eligibility and pre-authorizes behavioral health services in accordance with Medical Necessity Criteria, except for Emergency room services and certain services authorized by the CSA/LAA/LBHA
Utilization management to ensure quality and appropriateness of services
Management of information systems
Claims processing
Evaluation of the PBHS

10. Behavioral Health Services
Psychiatric Inpatient Care
Psychiatric Partial Hospitalization (PHP) (Medicaid only)
Respite services
Outpatient Mental Health Clinic services or individual mental health practitioner services
Psychiatric Rehabilitation Program (PRP)
onsite or offsite
Residential Rehabilitation (RRP)
Mobile Treatment services

11. Behavioral Health Services
Supported Living services
Supported Employment (SE)
Targeted Case Management services
Residential Crisis services
Mental Health related laboratory services
Early Intervention for substance use disorders
Outpatient Treatment services

12. Behavioral Health Services
Intensive Outpatient Program (IOP) services
Opioid Treatment services
Partial Hospitalization services
Residential Treatment
Low Intensity
Medium Intensity
High Intensity
Intensive
Withdrawal Management

13. Psychiatric Inpatient Care
Psychiatric inpatient care is a hospital-based service that provides intensive psychiatric treatment on a 24-hour basis — including weekends — to individuals experiencing severe psychiatric symptoms or behaviors that place them at risk of harming themselves or others. The inpatient service may include psychiatric and clinical evaluation, medication administration and management, individual and family counseling, group therapy, medical and nursing supervision and interventions, psychoeducation, and aftercare services.

14. PHP
PHP is an outpatient, short-term, intensive, psychiatric treatment service that parallels the intensity of services provided in a hospital, including medical and nursing supervision and interventions. PHP is an alternative to psychiatric inpatient care when the individual can safely reside in the community. This level of service is a covered benefit for Medicaid-eligible individuals only.

15. Respite Services
Respite services are provided on a short-term basis in the individual’s home or in an approved community-based setting and are designed to support the individual in remaining in his or her home by providing temporary relief to the individual’s caregivers.

16. Outpatient Psychiatric Treatment
Outpatient psychiatric treatment services may include psychiatric or clinical assessment and evaluation, individual therapy, group therapy, family therapy, family psychoeducation, or medication management. These services are provided by approved Outpatient Mental Health Centers (OMHCs), Federally Qualified Health Centers (FQHCs), Health Services Cost Review Commission (HCSRC)-regulated providers, or by individually licensed health professionals who are authorized under the Health Occupations Article to independently provide behavioral health services.

17. PRP Services
PRP services (onsite or offsite) are designed for individuals with severe and persistent mental illness (SPMI) to:
Develop or restore independent living and social skills, including the ability to make decisions regarding: life, self-care, illness management, and community participation
To promote access to and use of community resources to facilitate the individual’s integration into the community, thereby facilitating recovery, and preventing relapse and re-hospitalization

18. PRP Services
Services may be provided in an onsite facility, or in a setting most conducive to promoting the participation of the individual in community life.
PRP services include PRP basic case management functions, such as:
Assistance in securing entitlements
Coordination of services
Laisse with external services (somatic and behavioral health)

19. RRP Services
RRP services are designed for individuals with SPMI who require extensive psychiatric rehabilitation services and support in a structured community- based, home-like living environment to develop the daily living skills needed for independent functioning. RRP services provide graduated levels of care, to include intensive-level and general-level services, based on individual needs. Individuals are supported in moving through the levels of residential support services toward independent living or Permanent Supportive Housing (PSH).

20. Mobile Treatment Services
Mobile Treatment/Assertive Community Treatment (ACT) is an intensive, community-based service which provides assertive outreach, treatment, rehabilitation, and support to individuals with SPMI who may be without a home or for whom more traditional forms of outpatient treatment have been ineffective. Services are provided by a mobile, multidisciplinary team in the individual’s natural environment.

21. Supported Living Services
Supported Living services provide offsite rehabilitation and support for individuals with SPMI who are able to live in independent housing of their choice with flexible, individualized supports. Supported Living services are available to individuals transitioning from RRP services and individuals residing in independent, mainstream housing or PSH programs.

22. Supported Employment Services
Supported Employment (SE) services provide job development and placement, job coaching, and ongoing employment support to individuals with SPMI or emotional disturbance for whom competitive employment has not occurred, has been interrupted, or has been intermittent. These individualized services are provided to enable eligible individuals to choose, obtain, maintain, or advance within independent competitive employment, within a community-integrated work environment, consistent with their interests, preferences, and skills.

23. Targeted Case Management Services
Targeted Case Management (TCM) services are provided in the home or community in order to assist individuals in gaining access to the full range of behavioral health services, as well as to any additional needed medical, social, financial assistance or benefits, counseling, educational, housing, and other supportive services.
TCM services assist individuals, based on an assessment of needs, to link to services, advocate on behalf of the individual, and empower the individual to secure needed services
Services are time-limited, as individuals are effectively linked to needed resources and services

24. Residential Crisis Services
Residential Crisis services are short-term, intensive mental health and support services provided in a community-based, non-hospital, residential setting designed to:
Prevent a psychiatric inpatient admission
Provide an alternative to psychiatric inpatient admission
Shorten the length of inpatient stay

25. Laboratory Services
Mental Health related laboratory services include medically necessary tests and procedures performed by approved laboratories with a valid Medicaid provider number related to the psychiatric treatment rendered by psychiatrists in the PBHS to Medicaid-eligible individuals.

26. Early Intervention Services
Early Intervention services are intended to provide assessment and education for individuals experiencing substance use disorders. Through early intervention, referrals are made for additional recovery supports.

27. Level 1 Outpatient Treatment
Level 1 Outpatient Treatment services may include:
Initial evaluation
Individual counseling
Group counseling
Referral to ancillary services
Referral to recovery support services

28. IOP Services
Intensive Outpatient Program (IOP) services provide structured outpatient substance use disorder treatment for adults needing nine or more hours of direct services per week.
IOP services may include:
Individual counseling
Group counseling
Ambulatory detoxification

29. Level 1 Opioid Treatment
Level 1 Opioid Treatment services are medication management services which can be provided in an office-based setting by a psychiatrist or addiction medicine specialist. The individual should also be receiving substance use disorder counseling and be engaged with recovery support services.

30. Partial Hospitalization
Partial Hospitalization programs provide structured, individualized services for hours per week
Services may be either community-based or hospital-based

31. Residential Treatment
Residential Treatment services for individuals with substance related disorders are provided in correlation with the American Society of Addiction Medicine (ASAM) Levels of Care.
Services are provided in a structured residential environment, in combination with the corresponding level of treatment and ancillary services, to support and promote recovery.
Low Intensity (ASAM Level 3.1)- Five hours of low intensity treatment weekly
Medium Intensity (ASAM Level 3.3) hours of therapeutic activity weekly
High Intensity (ASAM Level 3.5)- minimum 36 hours of therapeutic activity weekly
Intensive (ASAM Level 3.7)- minimum 36 hours of therapeutic activity weekly

32. Withdrawal Management
Withdrawal Management services are available in all ASAM levels of care. Services are provided in accordance with ASAM from outpatient through inpatient detox.

33. Medicaid Eligibility
An individual is automatically eligible if she or he:
Has full Maryland Medicaid (not Qualified Medicare Beneficiary (QMB) or Specified Low Income Medicare Beneficiary (SLMB)
Has a diagnosis covered by the PBHS
Lives in Maryland voluntarily with intent to stay permanently
Is a U.S. citizen or certain lawfully admitted aliens

34. Eligibility
Once an individual meets financial eligibility for the PBHS (either through Medicaid or Uninsured Eligibility), he/she must then meet Medical Necessity criteria for the level of service requested.
Medical Necessity is determined based on:
Diagnosis
Functional Limitations
Clinical Risk

35. Eligibility Diagnostic Criteria:
There are some services which require a priority population diagnosis and others which have more broad diagnostic eligibility criteria

36. Eligibility
Services which do not require a Priority Population diagnosis:
Outpatient Treatment services
Targeted Case Management
Respite services
Residential Crisis services
Substance Use Disorder services

37. Eligibility
An individual must have a Priority Population diagnosis and meet the following functional limitations:
Impaired role functioning for at least two years, in least three of the following:
Inability to maintain independent employment
Social behavior that results in interventions by the mental health system
Inability, due to cognitive disorganization, to procure financial assistance to support living in the community
Severe inability to establish or maintain a personal support system
Need for assistance with basic living skills

38. Eligibility The diagnostic criteria may be waived if:
An individual committed as not criminally responsible is conditionally released from a BHA facility
An individual in a BHA facility with a length of stay of more than six months who requires RRP services, but who does not have a target diagnosis. This excludes individuals eligible for Developmental Disabilities services

39. Eligibility Excluded Diagnoses:
Mental disorders due to a general medical condition (personality changes due to a medical condition is included)
Sexual Dysfunctions
Sleep disorders
Antisocial Personality disorder
Psychological factors affecting medical condition
Relational problems
Other V Codes
Mental Retardation
Learning disorders
Motor Skills disorder
Communication disorders
Autism Spectrum disorders
Tic disorders
Delirium, Dementia, Amnestic, and other Cognitive disorders

40. Uninsured Eligibility
An individual without Maryland Medicaid may be eligible as “Eligible Uninsured.” Uninsured eligible individuals are those for whom the cost of medically necessary and appropriate community-based behavioral health services will be subsidized by the BHA because of the severity of the illness and financial need. Depending on the availability of state funding, services may be provided to these individuals who meet specific eligibility guidelines.

41. Uninsured Eligibility
The individual must:
Have a diagnosis covered by the PBHS
Have a Social Security number
Have applied for Maryland Medicaid, Supplemental Security Income (SSI), or Social Security Disability Insurance (SSDI)
Have applied for the Employed Individuals with Disabilities (EID) Program, if employed
Live in Maryland voluntarily with intent to stay permanently
Be a U.S. citizen or certain lawfully admitted aliens
Have gross income under 250 percent of the federal poverty level (FPL) — household generally includes spouses and children living with them

42. Uninsured Eligibility
AND must meet one of the following conditions:
Under age 19
Released from prison, jail, or a Department of Correction facility in the last three months
Is pregnant
Is an injection drug user
Has HIV/AIDS
Discharged from a Maryland-based psychiatric hospital in the last three months
Discharged from a Maryland-based medically monitored Residential Treatment Facility within the last 30 days

43. Uninsured Eligibility
Is requesting services required by HG order or referred by drug or probate court
Receiving services under an order of a Conditional Release
Is currently receiving SSDI for mental health reasons (exempt from financial eligibility requirement)
Is homeless within the state of Maryland (exempt from Maryland residency requirement)
Is a veteran (exempt from requirement to apply for Medical Assistance, SSI or SSDI as well as financial eligibility criteria)
Urgently needs outpatient mental health services and has been approved by the CSA/LBHA

44. Eligibility for SUD Services
Must be a Medicaid enrollee or be uninsured and meet the criteria for uninsured eligibility
Must meet medical necessity criteria based on the ASAM placement criteria for the corresponding level of care
Must be 18 years of age or older

45. Eligibility Summary
Individual must have Medicaid or meet criteria for Eligible Uninsured
Individual must meet Medical Necessity Criteria for the level of service requested:
Diagnosis
Functional limitations
Clinical risk

46. Service Access CSA/LAA/LBHA Directory
Maryland Association of Behavioral Health Authorities
Administrative Services Organization
Beacon Health Options Maryland

47. Navigating the PBHS
Questions?