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Medicaid Mental Health Benefits Overview of Coverage, Service Delivery and Utilization

Medicaid Mental Health Benefits Overview of Coverage, Service Delivery and Utilization. Mental Health and Substance Abuse Interim Committee Meeting August 14, 2006. Range of Service Coverage for Mental Health & Substance Abuse. Inpatient hospital Outpatient hospital

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Medicaid Mental Health Benefits Overview of Coverage, Service Delivery and Utilization

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  1. Medicaid Mental Health BenefitsOverview of Coverage, Service Delivery and Utilization Mental Health and Substance Abuse Interim Committee Meeting August 14, 2006

  2. Range of Service Coverage for Mental Health & Substance Abuse • Inpatient hospital • Outpatient hospital • Federally Qualified Health Centers & Rural Health Clinics • Physician Services • Clinic Services • Inpatient Psychiatric Services for participants <21 • Rehabilitative Services • School-based Services • Targeted Service Coordination

  3. Community-based MH Services • Mental Health Clinic services • medical model, provided in a facility with physician oversight • Psycho-Social Rehabilitative services • social model, provided in home & community • Targeted Service Coordination • social model, provided in home & community

  4. Population Data 2006 State of Idaho Population: 1.4 million Medicaid Caseload: 170,585 (12.0) National Prevalence Rates: Adults with SMI (5.4%) Adults with SPMI (2.6%) Children with SED (5%) Medicaid Children using MH services: 14,622 (0.01) Medicaid Adults using MH services: 8,984 (0.006) In 2000, just under 5,200 children and just under 5,000 adults were receiving services paid by Medicaid

  5. Regional Population Vs. Medicaid Enrollment

  6. Regional Enrollees Using MH Services

  7. Outcomes: ER

  8. Outcomes: MH Inpatient Admits

  9. Management Initiatives to Address Quality/appropriate Utilization • Rules (service definitions & expectations) • Limits on excessive utilization of partial care • MH pharmacy initiative • Legislative direction • On-site clinic reviews • New MH provider agreements & enrollment • Freeze on new provider applications • Roll-out provider credentialing system

  10. Medicaid Reform • HB 776: defines benefits according to health needs of different populations • HCR 48: provides further benefit parameters for Medicaid participants who are of average health • Federal authorization of three state plans: • Basic benefits for those of average health • Enhanced benefits for those with disabilities/special needs, and • A coordinated plan for dual eligible

  11. Basic Benefit Plan • Standard package of medical services available to all Medicaid enrollees. • Prevention & wellness benefits are expanded. • Mental health services. • Allows for 26 MH clinic services/annually with physician and FQHC exempted from limit. • Eliminates coverage of partial care, psycho-social rehabilitation, and service coordination which are preserved for individuals in the enhanced plan.

  12. Enhanced Plan • Includes all service coverage in the Basic Plan • Plus LTC coverage in institutions & community • Plus developmental disability coverage • Plus enhanced mental health coverage, including partial care, psycho-social rehabilitation, service coordination, and expanded mental health clinic services

  13. Reform Implementation Planning • New Medicaid applicants begin enrolling in new benefit plans (July 2006) • Expedited medical home enrollment (July 2006) • Health risk assessment (July 2006) • Rules publish (August) • Public Hearings (August) • Healthy school grants (September 2006) • Existing Medicaid enrollees move into new benefit plans at re-determination (over the next year)

  14. Horizon • Explore improvements to assessment process • Examine results of reform • Coordinate management oversight with new Behavioral Health Division • Participate on MH Transformation work group and steering committee • Support initiatives that provide for best practice, quality, and evidenced-based coverage

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