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Tags Posts tagged with "BH-MCO"

BH-MCO

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Photo by Markus Winkler from Pexels

Earlier this year, Community Care Behavioral Health (CCBH) notified Behavioral Health Services of Somerset and Bedford Counties, Inc. (BHSSBC) of their intent to withdraw from servicing the HealthChoices contract with the counties. In April, BHSSBC announced that they are working to transition its subcontract from CCBH to Magellan Behavioral Health Services of Pennsylvania, Inc., one of five behavioral health managed care organizations (BH-MCO) in the commonwealth, with an effective transition date of November 1, 2025. The primary goal is to provide a seamless transition for providers to prevent any disruption in the delivery of crucial behavioral health and/or substance use disorder services to their members.

All parties will continue to work collaboratively in an effort to promote the delivery of high-quality behavioral health and substance use disorder services to the community.

BHSSBC is one of 24 primary contractors in Pennsylvania’s Behavioral HealthChoices program. The Pennsylvania Department of Human Services (DHS) receives federal Medicaid funding and enters contracts with these primary contractors, who then enter contracts with BH-MCOs, which, among other responsibilities, manage a network of behavioral health providers.

Read BHSSBC’s latest correspondence here.

Contact RCPA Policy Associate Emma Sharp with any questions.

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In a presentation to the Medical Assistance Advisory Committee today, Office of Mental Health and Substance Abuse Services (OMHSAS) Deputy Secretary Jen Smith shared data that shows a significant increase over the past three years in behavioral health managed care organization (BH-MCO) decisions to deny services to their members or contracted providers.

In addition to denial data for calendar years 2022 through 2024, the report also provides data on grievances and complaints and defines what each of those is. Notably, the 2024 data does not include the fourth quarter of the year.

The most egregious service type denials are seen in two categories: 1) non-hospital residential withdrawal management, rehabilitation and halfway-house services for drug/alcohol abuse or substance use disorders; and 2) IBHS for children and adolescents with mental health or substance use disorders. Although the IBHS denials appear down slightly in 2024, when the fourth quarter data is added, the number is likely to increase. On the SUD side, even without fourth quarter data, denials for the non-hospital residential substance use disorder treatment services are up 45 percent over 2023.

The presentation breaks down the number of denials per year per BH-MCO since 2022.

The increases in denials in 2024 occurred at the same time OMHSAS acknowledged a significant miscalculation of capitation rates, resulting in underfunding of the behavioral health system, including primary contractors and BH-MCOs, by hundreds of millions of dollars.

Deputy Secretary Smith cautioned that there are multiple factors to consider when reviewing the data and increase in denials, including Pennsylvania’s SUD treatment system’s ongoing alignment with ASAM Criteria and the increased BH-MCO scrutiny on providers and individual BH-MCO interpretation of ASAM Criteria.

The full presentation is available here.

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The Office of Mental Health and Substance Abuse Services (OMHSAS) conducted Technical Assistance (TA) sessions regarding the updated Psychiatric Rehabilitation Services (PRS) regulations outlined in 55 Pa. Code Chapter 5230. These sessions were held in November 2024 for licensed PRS providers and Behavioral Health Managed Care Organizations (BH-MCO). The revised regulations became effective on January 18, 2025. To further support licensed PRS providers and BH-MCOs in implementing the new regulatory requirements, OMHSAS has released a Frequently Asked Questions (FAQ) document addressing common questions identified during those sessions. The FAQ document is now available; you can view the document here.

The FAQ document can also be found at the links below.

Comments and questions regarding this memorandum should be submitted via email to the DHS Psych Rehab inbox. You can also contact RCPA Policy Associate Emma Sharp.

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The Department of Human Services (Department) issued bulletin OMHSAS-16-03, “Revised Procedure for Waiver of Office of Mental Health and Substance Abuse Services (OMHSAS) Program Regulations and Standards,” on April 19, 2016, to update and clarify the procedure for submitting and processing of waiver requests to OMHSAS. OMHSAS has issued OMHSAS-24-04 to further update regulatory waiver language and the process to appeal a waiver determination. The issued bulletin can be found here. OMHSAS-16-03 is obsoleted by this bulletin.

OMHSAS licenses or approves community mental health facilities and agencies and other service providers operating in the Commonwealth of Pennsylvania. In accordance with this responsibility, the Department’s authorized agents periodically inspect mental health facilities and agencies. If regulatory requirements are met, certificates of compliance or approvals are granted under Article IX of the Human Services Code (62 P.S. §§ 901 – 922) or under Article X of the Human Services Code (62 P.S. §§ 1001 – 1080).

Pursuant to applicable regulations, a facility or agency may request a time limited waiver of regulations or program standards, or a portion of regulations or program standards. All regulatory waiver requests are subject to applicable waiver of standard requirements as outlined by each chapter or bulletin. In reviewing any such waiver request, OMHSAS will consider whether the facility or agency has demonstrated that substitute measures assure the health, safety, and welfare of all individuals who reside in the facility or who receive services from the agency.

Please contact RCPA COO and Mental Health Policy Director Jim Sharp with any questions.

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On July 19, 2024, the Office of Mental Health and Substance Abuse Services (OMHSAS) presented a Value-Based Purchasing (VBP) Provider Technical Assistance Webinar. The webinar, developed and presented by OMHSAS and their partner Mercer, provided an excellent overview of the VBP landscape and valuable guidance for providers to consider future efforts to incorporate VBPs into their service matrix.

OMHSAS supports providers interested in pursuing VBP programming to contact and collaborate with their respective BH-MCOs on VBP options. The Value-Based Purchasing (VBP) Provider Technical Assistance PowerPoint provides an outline of the information covered in the webinar. Should you have any questions or comments, please contact the OMHSAS VBP Resource Account via email.

If you have any additional questions, please contact RCPA Policy Directors Jason Snyder or Jim Sharp.

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Pennsylvania state Reps. Maureen Madden (D) and Jim Struzzi (R) last week issued a bi-partisan co-sponsorship memo seeking support among their colleagues for a bill that will force the Department of Human Services (DHS) to take a more active role in Pennsylvania’s Opioid Use Disorder Centers of Excellence (COE) while forcing consistency and eliminating interpretation among the five behavioral health managed care organizations (BH-MCO).

RCPA has been working to address multiple components of COE inconsistency, including: interpretation of COE definition; compliance with COE requirements; and policies, procedures, and payment models being implemented by the commonwealth’s five BH-MCOs.

RCPA, on behalf of its SUD treatment provider members that operate COEs, has repeatedly asked DHS to enforce consistency in the COE program from MCO to MCO. Despite DHS considering the COEs overall to be a “wild success,” they have refused to take any action to ensure the success continues in the transition to managed care. In the past several months, RCPA and provider members that operate COEs have testified in front of the House Democratic Policy Committee and the House Human Services Committee on the disjointed and burdensome transition of the COEs into Pennsylvania’s Medicaid state plan. You can read RCPA’s testimony or watch the Human Services hearing.

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