Benefit Plan Streamlining Spencer Clark, Patsy Coleman, Starleen Scott Robbins, DeDe Severino,...

Benefit Plan Streamlining

Spencer Clark, Patsy Coleman,Starleen Scott Robbins, DeDe Severino, Thelma Hayter

6/17/14 & 6/19/14

DMHDDSAS

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Benefit Plan StreamliningPurpose:

To reduce LME-MCO administrative resources necessary to appropriately

pull down DMHDDSAS Federal and State Single Stream funding.

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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICESBenefit Plan Streamlining

SummaryBenefits:• Reduces number of Benefit Plans

significantly (from 35 to 10).• Does not restrict eligibility for

State/Federal services.• Utilizes a subset of current Benefit

Plans, to reduce the number of Benefit Plan changes necessary (<10% of clients). 3


Benefits, Cont.• Utilizes DSM-5 diagnostic criteria,

ICD-9 diagnosis codes.• Allows LME-MCOs flexibility in

processing for ensuring eligibility for Benefit Plan and Services.

• Allows (but does not require) LME-MCOs to automate aspects of eligibility determination for some Benefit Plans. 4


Benefits, Cont.• Allows for extended end dates for

Benefit Plan eligibility (reducing potential for denials due to expiration of eligibility), as long as continued eligibility is ensured through business processes such as authorization.

• Allows for concurrency between most Benefit Plans.

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Benefits, Cont.• Should reduce the volume of denials

due to eligibility issues.

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New PolicyThe LME-MCO authorization and claims adjudication process must ensure that consumers who receive State/Federal funded services meet the eligibility criteria of the Service Definition or the Benefit Plan, whichever is strictest. The LME-MCO must maintain documentation to support this determination, and make it available to the Division or its agents upon request.

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Examples• Consumer has been previously

placed in AMI Benefit Plan, and provider is requesting authorization for outpatient treatment:– AMI Benefit Plan criteria is strictest, so

as long as the individual meets those criteria (diagnoses and functioning) then LME-MCO may choose to authorize

• Same consumer, and provider is requesting ACTT:– ACTT entrance criteria are strictest and

so must be met

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LME-MCO Actions Necessary1. Develop and/or revise business processes to ensure

individuals are eligible for services through UM and claims processing.

2. Train UM staff on revised Benefit Plan Eligibility Criteria, Benefit Plan Diagnosis Array, and Service Array.

3. Ensure providers are utilizing DSM5 by August 1, 2014 and understand the Benefit Plan eligibility criteria.

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LME-MCO Actions, Cont.4. Identify any consumers with Benefit Plans that are

being ended. For those who are not also in a continuing Benefit Plan, submit 834s to revise their eligibility, prior to submitting their first claim after July 31st, 2014. (NCTRACKS R2W: BR12008-R0010 or 11)

5. Consider whether to extend the end date on Benefit Plan eligibility for consumers who are unlikely to lose eligibility.

With procedures in place to support the new policy:• Individual with I/DD could have an ADSN ending date of 2099• Child with CMSED could have a benefit plan end the day before 18th birthday

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LME-MCO Actions, Cont.6. In NCTRACKS, add the GAP Benefit

Plan to Providers who are contracted to perform initial assessments.

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Benefit Plans• Semi-Automated Benefit Plan

Determination: Benefit Plan eligibility may be determined through a semi-automated process for five Benefit Plans: – AMI, CMSED, ASTER, CSSAD and GAP. – The automated portion of the process should

be based on the consumer’s age at the time of service and their primary diagnosis, where primary diagnosis is the main focus of attention or treatment.

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Benefit Plans• Individual Benefit Plan

Determinations: The remaining Benefit Plans: – ASWOM, ASCDR, ADSN, CDSN, and

AMVETmust continue to be determined individually, as they require review of several individual and clinical characteristics beyond the primary diagnosis and age group. 14


Benefit PlansGAP = Generic Assessment Payment • Effective 7/1/14• Collapses the 6 Age/Disability-specific

“Assessment Only” Benefit Plans into one• Intended to provide reimbursement for

individuals who need assessment but end up ineligible for any other Benefit Plan (no concurrency allowed)

• Covers up to two assessments per year• Eligibility is limited to 60 days

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AMI Benefit Plan RevisionAdd to the list of Level of Functioning or Risk Factors:ORi. Any individual with chronic mental illness who is currently stable but without continued treatment and supports would likely experience significant decompensation and deterioration of functioning. 16


Implementation • The Benefit Plans that are expiring

will be end-dated effective July 31, 2014 dates of service.

• Any consumers actively receiving services who are in these Benefit Plans only (and not in one of the remaining plans) will need to be switched to one of the remaining plans by this date.

• This is consistent with the August 1, 2014 implementation date for the DSM-5.

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Implementation has 2 Stages:1. Inclusion in DMHDDSAS Benefit Plans

after July 31, 2014 shall be based on the covered DSM-5 diagnoses and eligibility criteria listed in the Diagnosis Array and Eligibility Criteria documents.

2. ICD-9 diagnosis codes covered in FY14 (see the last tab in the attached Diagnosis Array workbook) will continue to be allowed for claims adjudication in NCTRACKS through the end of FY15, for the Benefit Plans that are not expiring.

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FY14 Diagnosis Array

FY14 Diagnosis Array from DMHDDSAS Website (dated 08-13)

ICD-9 Dx Code (Text)

DESCRIPTION ICD9 Code

expires 6/30/15

290.0 Senile dementia, uncomplicated Yes X X X X X290.10 Presenile dementia, uncomplicated Yes X X X X X290.11 Presenile dementia with delirium Yes X X X X X290.12 Presenile dementia with delusional features Yes X X X X X290.13 Presenile dementia with depressive features Yes X X X X X290.20 Senile dementia with delusional features Yes X X X X X290.21 Senile dementia with depressive features Yes X X X X X290.3 Senile dementia with delirium Yes X X X X290.40 Arteriosclerotic dementia, uncomplicated X X X X X

The yellow highlighted Benefit Plans remain in use during FY15, and the diagnoses marked with an X continue to be covered in NCTRACKS claims adjudication during the transition to DSM-5 through FY15. The pink highlighted diagnoses codes do not cross-walk directly to DSM-5 and are expiring at the end of FY15.

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FY15 Diagnosis ArrayNCDMHDDSAS Benefit Plan Diagnosis Array FY15

FY15 Benefit Plans: X = Covered; 0=Not Covered

ICD-9-CM ICD-10-CM DSM5 Disorder, Condition, or Problem Description

Disability AMI ASTER ASCDR ASWOM CMSED CSSAD AMVET

290.40 F01.50 Major vascular neurocognitive disorder, Probable, Without behavioral disturbance

MH 0 0 0 0 0 0 X

290.40 F01.51 Major vascular neurocognitive disorder, Probable, With behavioral disturbance

MH X 0 0 0 0 0 X

291.0 F10.121 Alcohol intoxication delirium, With mild use disorder

SUD 0 X X X 0 X 0

291.0 F10.221 Alcohol intoxication delirium, With moderate or severe use disorder

SUD 0 X X X 0 X 0

291.0 F10.231 Alcohol withdrawal delirium SUD 0 X X X 0 X 0291.0 F10.921 Alcohol intoxication delirium, Without use

disorderSUD 0 0 0 0 0 0 0

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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICESBenefit Plan Eligibility Criteria

exampleAdult Substance Abuse Women (ASWOM) Adult women who are ages 18 and over with a primary substance use disorder covered in the Benefit Plan Diagnosis Array AND who would benefit from assessment, initiation, engagement, treatment, continuity of treatment services, and/or supports for relapse prevention and recovery stability, AND who are:

1. Currently pregnant, OR

2. Has a dependent child(ren) under 18 years of age, OR

3. Is seeking custody of a child less than 18 years of age. Providers providing services to individuals in this benefit plan must meet all requirements set forth in the Substance Abuse Prevention and Treatment Block Grant (SAPTBG) for Women’s Set Aside funds, except for crisis/detox services.

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Service ArrayHighlighted cells indicate changes from previous publication. AMH AMH ASA ASA ASA ADD CMH CSA CDD

Service Code

Service Name

GAP AMI - Adult with Mental

Illness

AMVET - Veterans and their Families

ASCDR - Injecting

Drug User/Comm

unicable Disease

ASTER - Adult SUD Treatment

Engagement/Recovery

ASWOM - Adult SUD

Women

ADSN - Adult IDD

CMSED - Child with Serious

Emotional Disturbance

CSSAD - Child with Substance

Use Disorder

CDSN - Child IDD

H0014 Ambulatory Detox x x xH0015 SA Intensive Outpatient Program x x x x x H0019 Behavorial Health - Long Term Residential x xH0020 Opioid Treatment xH0031 Mental Health Assessment x x x x x x x x x xH0035 Mental Health - Partial Hospitalization x xH0040 Assertive Community Treatment Program xH2011 Mobile Crisis Management x x x x x x x x x xH2012-HA Mental Health - Day Treatment - Child x xH2014 Developmental Therapy Service Professional x x

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Concurrency Table

AMI ASTER ASCDR ASWOM CMSED CSSAD ADSN CDSN GAP AMVETAMI X X X

ASTER X X XASCDR X X XASWOM X X XCMSED X X XCSSAD X X XADSN X X XCDSN X X XGAP X X X X X X X X X X

AMVET X X X X X X X X X X

X Prohibit concurrent eligibility within the LME

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FY15 HierarchyBenefit Plan Abbreviation/Code Benefit Plan Description

FY15 Hierarchy

DMHAD NC Division of MH/DD/SA Services 1ASCDR Adult SA IV Drug Communicable Disease Risk 8ASWOM Adult SA Women 9CMSED Child with Serious Emotional Disturbance 12AMI Adult with Mental Illness 13CDSN Child with Developmental Disability 16ADSN Adult with Developmental Disability 17CSSAD Child with SA Disorder 19ASTER Adult SA Treatment Engagement and Recovery 20AMVET Adult MH Veteran and Family 21GAP Generic Assessment Payment 36

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Next• How to use the Diagnosis Array

workbook• Q&A• Policy questions regarding these

changes should be directed to Spencer Clark at [email protected].

• Technical questions should be emailed to [email protected].

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mailto:[email protected]

mailto:[email protected]

Benefit Plan Streamlining Spencer Clark, Patsy Coleman, Starleen Scott Robbins, DeDe Severino,...

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