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OMHSAS Q&A: Inpatient D&A Coverage for OCYF Youth
July 28, 2009

Beginning August 1, the HealthChoices program will cover inpatient non-hospital and residential detoxification and residential treatment for substance abuse services for youth in the child welfare and juvenile justice systems, regardless of service zone. The Office of Mental Health and Substance Abuse Services (OMHSAS) has received numerous questions regarding this change and provided PCPA with the following Occasionally Asked Questions About Drug & Alcohol (D&A) and Children In Substitute Care Out of Zone Policy Change.

Q. Who is telling the providers about this change in payment responsibility? 
A. A letter has been sent to the affected drug and alcohol providers. Also, the Pennsylvania Community Providers Association has issued Alerts to its members.

Q. What rates are you expecting the Behavioral Health Managed Care Organizations (BH-MCOs) to pay? County Children and Youth Agencies (CCYA) have a rate with each provider but the providers may want the BH-MCOs to pay more than what the CCYA pays. As MA enrollees, a lot of the requirements for providers will increase and be tougher. Documentation is a prime example here. Is OMHSAS expecting the BH-MCOs to negotiate rates prior to August 1?
A. Rate negotiations would be through the usual process and should occur prior to August 1. 

Q. Who is to pay the room and board portion of the rate for the D&A residential treatment – HealthChoices (HC) or CCYA?  
A. BH-MCOs can cover room and board costs for accredited facilities as in-lieu-of service.  The Center for Medicare and Medicaid Services recognizes JCAHO, COA, and CARF accreditation.   If not accredited, the room and board costs for children in substitute care (CISC) will be covered by the CCYA or Juvenile Probation Office.

Q. If the rate HC pays for D&A non-hospital rehabilitation is not to be all-inclusive, who sets the room and board rate (since providers don't currently break out this cost)?
A. BH-MCOs will have to have a way of separating treatment costs from room and board costs.

Q. What happens if the licensed provider isn't enrolled in PROMISe and doesn't have an NPI?  Will they get a deadline to get these enrollments in order to be paid starting August 1?
A.  Providers will need to be enrolled prior to getting paid.

Q. D&A facilities have always had to submit program descriptions to OMHSAS prior to PROMISe enrollment. Will these new providers need to do this and, if so, who will walk them through the process?
A. If provided as supplemental service there is no need to submit service descriptions.

Q. What happens if the rate previously paid by the CCYA is higher than the BH-MCO rate? Is OMHSAS expecting the BH-MCOs to pay the C&Y rate?   
A. BH-MCOs should use their usual process to negotiate a reasonable rate.

Q. What is the expected mechanism for determining medical necessity? Will it be the same as we do now with the local kids in non-hospital rehab?
A. We have not made any changes to the medical necessity requirements as a result of this financing change.

Q. How do we handle payments for clients placed prior to this change? Does payment responsibility remain with the CCYA until discharge? Or is the BH-MCO expected to review each current placement after the change date and then pay for those medically necessary clients retroactive to August 1?
A. The providers will be notified that they need to contact BH-MCOs prior to August 1 to get an authorization for August 1 onward. Authorization for applicable services must comply with MA Bulletins #99-96-01 and 99-03-13 and the revised Appendix V.

Q. What is OMHSAS' expectations around credentialing of these providers? It will be difficult to accomplish by August 1.
A. We expect the BH-MCOs to follow their customary credentialing process. For those providers not already in a managed care network, temporary credentialing can be considered until full credentialing is complete.

Q. Are there requirements for the out of state programs?
A.  If the BH-MCO is interested in contracting with a drug and alcohol provider located out-of-state, it should ensure that the facility is licensed in that state by the responsible drug and alcohol licensing body and enrolled in that state’s Medicaid program.  If the provider is not enrolled in the state’s Medicaid program, a determination of eligibility for Medicaid reimbursement should be made on a case by case basis.

 

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