To: From: BH Medical Group Providers IEHP Provider Relations Date: Subject: Expanded Mental Health Benefits The New Year has begun and the expanded mental health benefit for IEHP Medi-Cal Members is in full swing. We are pleased to be referring Medi-Cal Members to you and want to make sure you understand how your authorizations and claims payment will work. Attached is the previous letter announcing the expanded programs for 2014 for your reference. The key elements you may be concerned about are: Your contract now covers all IEHP Lines of Business in order to incorporate Medi-Cal Members in addition to the Medicare DualChoice Members you have been serving. Authorizations, payment rates, Web Forms and claims submission are all the same; you will receive the same Medicare based payment rate regardless of whether the Member is Medicare DualChoice or Medi-Cal. If you currently receive referrals from the County to treat Medi-Cal Members who meet Specialty Mental Health Criteria you will continue to work with the County and now will also receive IEHP Medi-Cal referrals for Members who do not meet Specialty Mental Health Criteria from IEHP. IEHP will directly authorize and pay you for treating these Medi-Cal Members who do not qualify for services within the County Mental Health program. If you are not working with the County Medi-Cal program you will receive Medi-Cal referrals from IEHP and your contract with IEHP enables you to treat these Members like you currently treat our Medicare DualChoice Members. Please schedule these new Medi-Cal referrals that you will receive from IEHP as you would our Medicare DualChoice referrals. We are expecting a substantial increase in referrals as Members learn of the newly available benefit that provides access to mental health professionals for mild and moderate mental health conditions. Substance Abuse treatment for Medi-Cal Members will continue to be provided through the County Drug Medi-Cal program. The BH Care Management Team will be screening Members to determine if they need Specialty Mental Health services through the County Mental Health Programs due to more severe impairment and we will do our best to refer Members to you who do not need this Specialty Mental Health level of care. However, our screening is not perfect and you may occasionally evaluate a Member who turns out to meet Specialty Mental Health criteria. In such cases, you are asked to describe the Member s condition and request that the IEHP BH Care Management Team transition the Member to the appropriate County Mental Health Program. Your authorization will continue to cover the additional treatment you provide until the Member is fully transitioned as you will have to provide for continuity of care to prevent patients you have evaluated from experiencing a preventable lapse in medically necessary care. You can document the Members Specialty Mental Health condition on your initial Coordination of Care Web form and we will handle the initiation of Specialty Mental Health Services through the County. You are encouraged to also
Page 2 of 5 call the IEHP BH Care Management Team and we will assist the Member in getting to the appropriate level of care. A description of Specialty Mental Health criteria is attached for you to use as a reference guide when you come across those Members that present more severe mental health conditions. All Medi-Cal Members needing psychiatric hospital care will be referred immediately to a County contracted facility because all psychiatric inpatient services remain the responsibility of the County Mental Health program. We are excited about being able to offer a full range of mental health services to our 680,000 (and growing) Medi-Cal Members and to be able to maintain the same level of payment for our providers as we have for our Medicare population. Please feel free to call us at (909) 890-2362 if you have any questions or concerns. Enclosure: 2013 BH Amendment Specialty Mental Health Criteria
Page 3 of 5 September 26, 2013 Dear Behavioral Health Provider: IEHP is working on preparing our Behavioral Health Network for the current changes in the benefits we will be providing to our Members in 2014. First, we are pleased to announce that as of January 1, 2014, IEHP will be providing a full range of mental health services to our Medi-Cal Members (estimated population of 700,000 in February 2014) who do not meet the severity criteria for treatment within the County Mental Health Departments. Based on the needs of these Members we are anticipating a 500% increase in referrals to our directly contracted Behavioral Health Network starting in January of 2014 for mild behavioral health conditions. Additionally, as of April 1, 2014 IEHP will begin enrolling dual eligible Medicare/Medi Cal Members as the Coordinated Care Initiative is launched in California. Our projections indicate over the subsequent 12 months we will see a three-fold increase in the Behavioral Health Services IEHP is directly managing and referring to you, our directly contracted BH providers. Rather than create two rate schedules, one for the Medi Cal and one for the Medi/Medi membership, IEHP has decided to have one rate schedule for all lines of business which will be based on the higher Medicare fee schedule. For this reason, and to make sure we have updated our contract with you we are sending you the enclosed revisions to your contract. As you may recall, a couple of State level changes occurred in the year 2013 that may have directly impacted your practice in relationship to your business with the Inland Empire Health Plan (IEHP). The year began with a change in the CPT codes behavioral health providers can bill for services rendered. In addition, another change was IEHP s 58,000 Health Families Members had their healthcare benefits switched to Medi-Cal. This makes IEHP s behavioral network primarily focused on providing services to our Medicare DualChoice Members. Therefore, IEHP is updating its behavioral agreement to reflect the CPT codes which you can bill and a corresponding reimbursement methodology based on Medicare rates. Enclosed please find a new agreement for your review. Please contact your Contract Manager with comments and/or questions. We would appreciate receiving your signed agreement by October 07, 2013. Sincerely, David Carrish Peter Currie, Ph. D. Director of Provider Contracting Clinical Director of Behavioral Health
Page 4 of 5 Specialty Mental Health Criteria IEHP Medi-Cal Members must meet the following Specialty Mental Health criteria to be eligible to receive MH services through County Behavioral/Mental Health. This criteria should be used by all IEHP BH providers when evaluating Members to ensure they receive treatment in the correct system of care. All THREE CRITERIA (A, B, and C) MUST BE MET! A: Diagnosis: Included Diagnosis: Pervasive Developmental Disorders, except Autistic Disorders Disruptive Behavior and Attention Deficit Disorders Feeding and Eating Disorders of Infancy and Early Childhood Elimination Disorders Other Disorders of Infancy, Childhood, or Adolescence Schizophrenia and other Psychotic Disorders, except Psychotic Disorders due to a General Medical Condition Mood Disorders, except Mood Disorders due to a General Medical Condition Anxiety Disorders, except Anxiety Disorders due to a General Medical Condition Somatoform Disorders Factitious Disorders Dissociative Disorders Paraphilias Gender Identity Disorder Eating Disorders Impulse-Control Disorders Not Elsewhere Classified Adjustment Disorders Personality Disorders, excluding Antisocial Personality Disorder Medication-Induced Movement Disorders related to other included diagnosis An Included Diagnosis when an Excluded Diagnosis is also Present Excluded Diagnosis: (Not Eligible for Specialty Mental Health Services thru County MH) Autistic Disorder Learning Disorders Motor Skills Disorder Community Disorders Autistic Disorder Other Pervasive Developmental Disorders are Included Tic Disorders Delirium, Dementia, Amnesic, and Other Cognitive Disorders Mental Disorders Due to a General Medical Condition Substance-Related Disorder Sexual Dysfunction Sleep Disorders
Page 5 of 5 Antisocial Personality Disorder Other Conditions That May be a Focus of Clinical Attention, Except Medication Induced Movement Disorders Which are Included Mental Retardation B. Impairment Criteria: A beneficiary may receive services for an included diagnosis when an excluded diagnosis is also present. Must have one of the following as a result of the mental disorder(s) identified in the diagnostic criteria. A significant impairment in an important area of life functioning. A probability of significant deterioration in an important area of life functioning. Children also qualify if there is a probability the child will not progress developmentally as individually appropriate. C. Intervention-Related Criteria: Must have all of the following: The focus of proposed intervention is to address the condition identified in impairment criteria. It is expected the beneficiary will benefit from the proposed intervention by significantly diminishing the impairment, or preventing significant deterioration in an important area of life functioning, and/or for children it is probable the child will progress developmentally as individually appropriate. The condition would not be responsive to physical healthcare-based treatment.