1. Colorado Medicaid Colorado Medicaid Community Mental Health Services Program Working Together for Better Outcomes “Improving access to cost-effective, quality health care services for Coloradans.”

2. Colorado Medicaid Today’s Topics Community Mental Health Services Program Overview Fee for Service Medicaid BHO Services Dual Diagnoses Care Coordination Grievances and Appeals Resources

3. Colorado Medicaid Community Mental Health Services Program Overview Statewide mandatory client enrollment for all Medicaid eligibles Capitated managed care program Operated under a federal 1915(b) waiver Comprehensive mental health benefit consisting of State Plan & 1915(b)(3) services

4. Colorado Medicaid Community Mental Health Services Program Overview Five Behavioral Health Organizations (BHOs) function as the managed care organizations Each BHO has a provider network composed of Community Mental Health Centers (CMHCs), FQHCs and other essential community providers, non-profit organizations, and individual facilities/practitioners. BHOs are required to maintain an “adequate provider network” at all times.

5. Colorado Medicaid Community Mental Health Services Program Overview Individuals must be Medicaid eligible, have a covered mental health diagnosis,;services must be medically necessary and be covered in the BHO contract. Each BHO must provide State Plan services, as well as a package of 1915(b)(3) waiver services, known as Alternative services, which include: –Assertive Community Treatment –Vocational Services –Home-based Counseling for Families –Clubhouses and Drop-In Centers –Respite Care –Intensive Case Management

6. Colorado Medicaid Fee-for-Service (FFS) Medicaid Mental Health Services –Individuals not covered under the CMHS Program may receive state plan services on a FFS basis through participating Medicaid providers. –Services are not as comprehensive and individuals must find their own Medicaid providers. –Individuals not covered include a few who have been granted official exemption from the program, and individuals who may have behavioral health needs but do not have a covered diagnosis (e.g. DD or TBI).

7. Colorado Medicaid Fee-for-Service (FFS) Medicaid Substance Use Disorder (SUD) Services –In 2006, a limited SUD outpatient benefit was introduced under FFS Medicaid. –Services include: Substance abuse assessment Individual and family therapy Group therapy Alcohol/drug screening Targeted case management Social/ambulatory detox services

8. Colorado Medicaid CMHS Program – BHO Services Enrollment in the Program –When Medicaid eligibility is confirmed, consumers are automatically assigned to a BHO based on the county in which they reside. –New BHO Members are sent an enrollment packet that contains a Member handbook and information on how to access providers, services and assistance. –All BHOs also have a Member website with program and mental health information.

9. Colorado Medicaid CMHS Program – BHO Services Currently, Colorado is served by five BHOs: –Colorado Access/Access Behavioral Care (Denver metro) –Behavioral Healthcare, Inc. (Denver east) –Colorado Health Partnerships, LLC (western slope and southern Colorado) –Foothills Behavioral Health Partners, LLC (Denver west) –Northeast Behavioral Health Partnership, LLC (NE Colorado) The current BHO contract expires on 6/30/12 and has two additional one-year renewals. Medicaid behavioral health services may be managed differently by 2014.

10. Colorado Medicaid Behavioral Health Organization (BHO)Counties Served Access Behavioral Care (ABC) 10065 E. Harvard Ave., Suite 600 Denver, CO 80231 303-751-9030 1-800-984-9133 Denver Behavioral HealthCare Inc. (BHI) 6801 S. Yosemite St., Suite 201 Centennial, CO 80112 303-889-4805 1-877-349-7379 Adams, Arapahoe, Douglas Foothills Behavioral Health Partners (FBHP) 9101 Harlan, Suite100 Westminster, CO 80031 303-432-5950 1-866-245-1959 Boulder, Broomfield, Clear Creek, Gilpin, Jefferson BHO Service Areas

11. Colorado Medicaid Northeast Behavioral Health Partnership (NBHP) 1300 N. 17th Ave. Greeley, CO 80631 970-347-2366 1-888-296-5827 Cheyenne, Elbert, Kit Carson, Larimer, Lincoln, Logan, Morgan, Phillips, Sedgwick, Washington, Weld, Yuma Colorado Health Partnerships (CHP) Colorado Health Networks 7150 Campus Dr., Suite 300 Colorado Springs, CO 80920 1-800-804-5008 Alamosa, Archuleta, Baca, Bent, Chaffee, Conejos, Costilla, Crowley, Custer, Delta, Dolores, Eagle, El Paso, Fremont, Garfield, Grand, Gunnison, Hinsdale, Huerfano, Jackson, Kiowa, Lake, La Plata, Las Animas, Mesa, Mineral, Moffat, Montezuma, Montrose, Otero, Ouray, Park, Pitkin, Prowers, Pueblo, Rio Blanco, Rio Grande, Routt, Saguache, San Juan, San Miguel, Summit, Teller BHO Service Areas

12. Colorado Medicaid

13. What do the BHOs Do? BHOs ensure that the program complies with federal, state and contract requirements. BHOs are required to: Manage behavioral health services for all Members in their service area and for Members from other service areas, when needed. Process consumer grievances: the BHO Director of Member and Family Affairs investigates and responds to grievances. If a client is not happy with the response, the grievance may be reviewed by a Contract Manager at HCPF.

14. Colorado Medicaid What do the BHOs Do? Monitor and report statistics to HCPF including: Access to Care: Do clients receive appointments within specified timeframes? Are clients able to access more intensive levels of treatment when needed? Provider Network: Are there sufficient providers within the geographic area to meet client needs? Are they accessible to clients? Benefit Limits: Do clients exhaust their benefit limits while continuing to need services? Grievance and Appeals: Are there trends or patterns evident in client grievances and appeals that should be addressed?

15. Colorado Medicaid BHO Mental Health Services Include both mandatory State Plan services and 1915(b) waiver services. State Plan services are available to all Medicaid members statewide. Waiver services may vary by location, capacity, and populations served. Services are provided within a Recovery Model based on the following premises: –Recovery from mental illness can and does happen –Recovery is a highly individualized process, occurring over time –The goal is Member empowerment, community reintegration, and normalization of the life environment –Members, families and advocates should be included in the treatment planning and decision-making process

16. Colorado Medicaid Medicaid State Plan Services Inpatient Hospitalization –24-hour care in a licensed hospital, limited to 45 days/year Outpatient Programs –Services in a hospital or other health care facility/office, but patients do not stay 24 hours/day, including: Psychiatrist Individual psychotherapy Group psychotherapy Family psychotherapy Mental health assessment Medication management Outpatient day treatment Emergency/crisis services Case management School-based mental health services

17. Colorado Medicaid 1915(b) Waiver Services Also known as (b)(3) services, these services are designed to save costs with the goal of applying dollars saved to providing additional services. These services include: Vocational Services –Designed to assist adult and adolescent Members who are ineligible for State vocational rehabilitation services Assertive Community Treatment (ACT) –Comprehensive, highly individualized services to Members with severe and persistent mental illness that seriously impairs their functioning in community living, 24/7, 365 days/year Home-Based Services for Children and Adolescents –Therapeutic services provided in the home, involving family members

18. Colorado Medicaid 1915(b) Waiver Services Intensive Case Management –Community-based services for clients at risk of hospitalization, incarceration and/or homelessness due to multiple needs and impaired level of functioning Respite Care –Temporary or short-term care provided clients with mental illness, designed to give parents/caregivers a break in order to emotionally recharge and become better prepared to handle the normal day-to- day challenges Clubhouses, Drop-in Centers –Clients plan and conduct programs and activities in a club-like setting, working in partnership with Staff –Clients utilize their skills for clerical work, data input, meal preparation, providing resource information, peer counseling –Peer specialists play a vital part in these services.

19. Colorado Medicaid 1915(b) Waiver Services Recovery Services –Promote self-management of psychiatric symptoms, relapse prevention, treatment choices, mutual support, and rights protection –Provide social supports and a lifeline for clients who have difficulties developing and maintaining relationships –Include peer counseling and support services, peer-run employment services, recovery groups, warm lines and advocacy services Prevention/Early Intervention Services –Proactive efforts to educate and empower clients to choose and maintain healthy life behaviors and lifestyles that promote mental health

20. Colorado Medicaid 1915(b) Waiver Services Residential Treatment –24-hour care provided in a non-hospital, non-nursing home setting and a therapeutic environment –Clients may need supervision for medication management, daily living tasks, safety, management of time and activities –For placement by BHOs based on client mental health needs –Facilities: Psychiatric Residential Treatment Facility (PRTF) Residential Child Care Facility (RCCF) – (formerly TRCCF) –Families who are denied residential treatment by the BHO may request an evaluation under the Child Mental Health Treatment Act (CMHTA).

21. Colorado Medicaid Dual Diagnoses All Medicaid members enrolled in a BHO may request a mental health assessment. If a Medicaid member is denied a MH assessment due to the presence of a non-covered diagnosis (e.g. TBI or DD), clients should do one of the following (in order of priority): –Contact the BHO Office of Member and Family Affairs –Contact the Medicaid Ombudsman for Managed Care –Contact the Department’s BHO contract manager With the help of a stakeholder group, in 2009 the Department developed a set of assessment and treatment criteria for people with TBI and a possible mental illness. –These guidelines have been distributed to all BHO providers; however, retraining on an ongoing basis is necessary.

22. Colorado Medicaid Grievances and Appeals Client grievances –Grievances are oral or written expressions of dissatisfaction about any matter other than an Action. –Clients may request Final Grievance Resolutions be reviewed by the Department Client Appeals –Requests for a review of an Action: denial of a type or level of service, reduction or suspension of a previously authorized service, denial of payment for a service, failure to provide service in a timely manner. –Notice of action must be provided in writing to the client within contractual guidelines and must include how to access a State fair hearing, timelines, etc.

23. Colorado Medicaid Care Coordination Care coordination includes the coordination of all care, including non-medical care, that affects an individual’s health and wellbeing. BHOs are required to coordinate services with community agencies, behavioral health providers, and some primary care providers. The new Regional Care Collaborative Organizations (RCCOs) are responsible for coordinating care with BHOs, primary care medical practices (PCMPs), long-term care, community organizations, and other state agencies.

24. Colorado Medicaid Care Coordination All agencies under contract with Medicaid to provide health care to Medicaid clients need to actively engage in sharing of information, become aware of and educated about other services and systems, and coordinate services efficiently and effectively for clients. Clients should be encouraged to sign releases of information upon initiating care so that providers may share information needed to coordinate care. Exceptions to this information sharing under HIPAA are psychotherapy notes and information regarding substance abuse treatment, which fall under stricter federal regulations. State level efforts are being made towards development of electronic health records and common outcomes for coordinating care and maximizing federal and general fund dollars.

25. Colorado Medicaid Medicaid Ombudsman The Ombudsman program was established to assist clients enrolled in Medicaid managed care organizations (MCOs). The Ombudsman may: –Assist clients in articulating and filing a complaint (grievance) –Act as the client’s designated representative, upon request –Facilitate problem resolution between the client and the MCO –Refer clients to other agencies, as appropriate –Provide clients with information on their rights and responsibilities under Medicaid Managed Care –Provide information on exclusions and limitations that may be placed on care, services, equipment or other benefits The Ombudsman is not required to assist clients with issues relating to fee-for-service Medicaid.

26. Colorado Medicaid Medicaid Ombudsman BHOs are required to share client information with the Medicaid Ombudsman without a signed release of information to facilitate problem resolution. Clients may call, write or e-mail the Ombudsman with concerns and/or requests for assistance Contact info & location: –Program contract is held by Maximus, Inc., 303 E. 17 th Avenue, #105, Denver, CO 80203 –Barbara Harrison (303) 830-3560 barbarajharrison@maximus.com barbarajharrison@maximus.com –Janine Vincent (303) 830-3560 –JanineMVincent@maximus.comJanineMVincent@maximus.com

27. Colorado Medicaid Resources Each BHO Office of Member and Family Affairs exists to assist Medicaid clients with accessing services, locating providers, and resolving problems. –Contact information for BHOs is available online at: Medicaid BHO Contact Information –BHOs may not be aware of an issue at the local level, but are tasked with ensuring access to care and protecting client rights. Medicaid Ombudsman for Managed Care (previous slides) Department staff / contract managers

28. Colorado Medicaid Questions? Marceil Case, Behavioral Health Specialist –Marceil.Case@state.co.usMarceil.Case@state.co.us –(303) 866-3054 direct (303) 866-2803 fax

29. Colorado Medicaid Thank You!