Mental Health The parties recognize the importance of supporting and promoting a psychologically healthy workplace and as such will adhere to all applicable statutes, policy, guidelines and regulations pertaining to the promotion of mental health.
Mental Health Services This agreement covers medically necessary services for the treatment of mental health disorders in a general or specialty hospital or outpatient facilities that are: • reviewed and approved by us; and • licensed under the laws of the State of Rhode Island or by the state in which the facility is located as a general or specialty hospital or outpatient facility. We review network and non-network programs, hospitals and inpatient facilities, and the specific services provided to decide whether a preauthorization, hospital or inpatient facility, or specific services rendered meets our program requirements, content and criteria. If our program content and criteria are not met, the services are not covered under this agreement. Our program content and criteria are defined below.
Community Mental Health Center Services Assertive Community Treatment Staffing Full Time Equivalents Community Mental Health Center March 2021 December 2020 Nurse Masters Level Clinician/or Functional Support Worker Peer Specialist Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner 01 Northern Human Services - Wolfeboro 1.00 0.00 0.00 0.57 6.81 0.27 8.27 0.25 01 Northern Human Services - Berlin 0.34 0.31 0.00 0.00 3.94 0.14 4.17 0.14 01 Northern Human Services - Littleton 0.00 0.14 0.00 0.00 3.28 0.29 3.31 0.29 02 West Central Behavioral Health 0.60 1.00 0.00 0.00 5.40 0.30 5.90 0.30 03 Lakes Region Mental Health Center 1.00 1.00 0.00 1.00 5.00 0.40 7.00 0.38 04 Riverbend Community Mental Health Center 0.50 1.00 6.90 1.00 10.40 0.50 10.50 0.50 05 Monadnock Family Services 1.91 2.53 0.00 1.12 11.17 0.66 10.32 0.62 06 Greater Nashua Mental Health 1 1.00 1.00 3.00 1.00 7.65 0.15 8.50 0.15 06 Greater Nashua Mental Health 2 1.00 1.00 4.00 1.00 8.65 0.15 8.50 0.15 07 Mental Health Center of Greater Manchester-CTT 1.33 10.64 2.00 0.00 19.95 1.17 21.61 1.21 07 Mental Health Center of Greater Manchester-MCST 1.33 9.31 3.33 1.33 19.95 1.17 25.27 1.21 08 Seacoast Mental Health Center 1.00 1.10 5.00 1.00 10.10 0.60 10.10 0.60 09 Community Partners 0.50 0.00 3.40 0.88 7.28 0.70 7.41 0.70 10 Center for Life Management 1.00 0.00 2.28 1.00 6.71 0.46 6.57 0.46 Total 12.51 29.03 29.91 9.33 126.29 6.96 137.43 6.96 2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies Community Mental Health Center Substance Use Disorder Treatment Housing Assistance Supported Employment March 2021 December 2020 March 2021 December 2020 March 2021 December 2020 01 Northern Human Services - Wolfeboro 1.27 1.27 5.81 6.30 0.00 0.40 01 Northern Human Services - Berlin 0.74 0.74 3.29 3.29 0.00 0.23 01 Northern Human Services - Littleton 1.43 1.29 2.14 2.14 1.00 1.00 02 West Central Behavioral Health 0.20 0.20 4.00 0.40 0.60 0.60 03 Lakes Region Mental Health Center 1.00 3.00 5.00 7.00 2.00 2.00 04 Riverbend Community Mental Health Center 0.50 0.50 9.40 9.50 0.50 0.50 05 Monadnock Family Services 1.69 1.62 4.56 4.48 0.95 1.18 06 Greater Nashua Mental Health 1 6.15 7.15 5.50 6.50 1.50 1.50 06 Greater Nashua Mental Health 2 5.15 5.15 6.50 6.50 0.50 0.50 07 Mental Health Center of Greater Manchester-CCT 14.47 15.84 13.96 15.62 2.66 2.66 07 Mental Health Center of Greater Manchester-MCST 6.49 7.86 15.29 19.28 1.33 2.66 08 Seacoast Mental Health Center 2.00 2.00 5.00 5.00 1.00 1.00 09 Community Partners 1.20 1.20 4.50 4.50 1.00 1.00 10 Center for Life Management 2.14 2.14 5.42 5.28 0.29 0.29 Total 44.43 49.96 90.37 99.39 13.33 15.52 Revisions to Prior Period: None. Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report. Notes: Data compiled 04/26/2021. For 2b: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, but rather the quantity of staff available to provide each service. If staff are trained to provide multiple service types, their entire FTE value is credited to each service type.
Behavioral Health Services Behavioral health services include the evaluation, management, and treatment for a mental health or substance use disorder condition. For the purpose of this plan, substance use disorder does not include addiction to or abuse of tobacco and/or caffeine. Mental health or substance use disorders are those that are listed in the most updated volume of either: • the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association; or • the International Classification of Disease Manual (ICD) published by the World Health Organization. This plan provides parity in benefits for behavioral healthcare services. Please see Section 10 for additional information regarding behavioral healthcare parity. Inpatient This plan covers behavioral health services if you are inpatient at a general or specialty hospital. See Inpatient Services in Section 3 for additional information. Residential Treatment Facility This plan covers services at behavioral health residential treatment facilities, which provide: • clinical treatment; • medication evaluation management; and • 24-hour on site availability of health professional staff, as required by licensing regulations. Intermediate Care Services This plan covers intermediate care services, which are facility-based programs that are: • more intensive than traditional outpatient services; • less intensive than 24-hour inpatient hospital or residential treatment facility services; and • used as a step down from a higher level of care; or • used a step-up from standard care level of care. Intermediate care services include the following: • Partial Hospital Program (PHP) – PHPs are structured and medically supervised day, evening, or nighttime treatment programs providing individualized treatment plans. A PHP typically runs for five hours a day, five days per week. • Intensive Outpatient Program (IOP) – An IOP provides substantial clinical support for patients who are either in transition from a higher level of care or at risk for admission to a higher level of care. An IOP typically runs for three hours per day, three days per week.
Behavioral Health Services – Mental Health and Substance Use Disorder Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Chiropractic Services In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Dental Services - Accidental Injury (Emergency) Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Early Intervention Services (EIS) Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Education - Asthma Asthma management 0% - After deductible 40% - After deductible Emergency Room Services Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.
Clinical Management for Behavioral Health Services (CMBHS) System The CMBHS is the official record of documentation by System Agency. Grantee shall:
Medically Necessary Services for the State plan services in Addendum VIII. B medically necessary has the meaning in Wis. Admin. Code DHS §101.03(96m): services (as defined under Wis. Stat. § 49.46
Behavioral Health Behavioral health services, with the exception of Medicaid Rehabilitation Option (MRO) and 1915(i) services, are a covered benefit under the Hoosier Healthwise program. The Contractor shall be responsible for managing and reimbursing all such services in accordance with the requirements in this section. In furnishing behavioral health benefits, including any applicable utilization restrictions, the Contractor shall comply with the Mental Health Parity and Additions Equity Act (MHPAEA). This includes, but is not limited to: Ensuring medical management techniques applied to mental health or substance use disorder benefits are comparable to and applied no more stringently than the medical management techniques that are applied to medical and surgical benefits. Ensuring compliance with MHPAEA for any benefits offered by the Contractor to members beyond those otherwise specified in this Scope of Work. Making the criteria for medical necessity determinations for mental health or substance use disorder benefits available to any current or potential members, or contracting provider upon request. Providing the reason for any denial of reimbursement or payment with respect to mental health or substance use disorder benefits to members. Providing out-of-network coverage for mental health or substance use disorder benefits when made available for medical and surgical benefits. The Contractor shall assure that behavioral health services are integrated with physical care services, and that behavioral health services are provided as part of the treatment continuum of care. The Contractor shall develop protocols to: Provide care that addresses the needs of members in an integrated way, with attention to the physical health and chronic disease contributions to behavioral health; Provide a written plan and evidence of ongoing, increased communication between the PMP, the Contractor and the behavioral health care provider; and Coordinate management of utilization of behavioral health care services with MRO and 1915(i) services and services for physical health.
Health Services At the time of employment and subject to (b) above, full credit for registered professional nursing experience in a school program shall be given. Full credit for registered professional nursing experience may be given, subject to approval by the Human Resources Division. Non-degree nurses shall be placed on the BA Track of the Teachers Salary Schedule and shall be ineligible for movement to any other track.
Covered Health Care Services We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received: • as an inpatient; • as an outpatient; • in your home; • in a doctor’s office; or • from a pharmacy. Also coverage differs depending on whether: • the health care provider is a network provider or non-network provider; • deductibles (if any), copayments, or maximum benefit apply; • you have reached your plan year maximum out-of-pocket expense; • there are any exclusions from coverage that apply; or • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.
