DMHDDSAS
Benefit Plan Streamlining
Spencer Clark, Patsy Coleman,
Starleen Scott Robbins,
DeDe Severino, Thelma Hayter
6/17/14 & 6/19/14
N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Benefit Plan Streamlining
Purpose:
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 SERVICES
Benefit Plan Streamlining Summary
Benefits:
• 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).
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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
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.
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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Benefits, Cont.
• Should reduce the volume of denials due to
eligibility issues.
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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
New Policy
The 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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
LME-MCO Actions Necessary
1. 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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Benefit Plans
• Semi-Automated Benefit Plan Determination: Benefit
Plan eligibility may be determined through a semiautomated 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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Benefit Plans
• Individual Benefit Plan Determinations: The
remaining Benefit Plans:
– ASWOM, ASCDR, ADSN, CDSN, and AMVET
must continue to be determined individually, as they
require review of several individual and clinical
characteristics beyond the primary diagnosis and age
group.
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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Benefit Plans
GAP = 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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AMI Benefit Plan Revision
Add to the list of Level of Functioning or Risk Factors:
OR
i.
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.
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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Implementation
• The Benefit Plans that are expiring will be enddated 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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
FY14 Diagnosis Array
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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
FY15 Diagnosis Array
NCDMHDDSAS Benefit Plan Diagnosis Array FY15
FY15 Benefit Plans: X = Covered; 0=Not Covered
ICD-9-CM ICD-10-CM
290.40
F01.50
290.40
F01.51
291.0
F10.121
291.0
F10.221
291.0
291.0
F10.231
F10.921
DSM5 Disorder, Condition, or Problem Disability
Description
Major vascular neurocognitive disorder,
MH
Probable, Without behavioral disturbance
Major vascular neurocognitive disorder,
MH
Probable, With behavioral disturbance
Alcohol intoxication delirium, With mild
SUD
use disorder
Alcohol intoxication delirium, With
SUD
moderate or severe use disorder
Alcohol withdrawal delirium
SUD
Alcohol intoxication delirium, Without use SUD
disorder
AMI
ASTER ASCDR ASWOM CMSED CSSAD AMVET
0
0
0
0
0
0
X
X
0
0
0
0
0
X
0
X
X
X
0
X
0
0
X
X
X
0
X
0
0
0
X
0
X
0
X
0
0
0
X
0
0
0
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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Benefit Plan Eligibility Criteria example
Adult 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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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Service Array
Highlighted cells indicate changes from previous publication.
GAP
Service
Code
Service Name
H0014
H0015
H0019
H0020
H0031
H0035
H0040
H2011
H2012-HA
H2014
Ambulatory Detox
SA Intensive Outpatient Program
Behavorial Health - Long Term Residential
Opioid Treatment
Mental Health Assessment
Mental Health - Partial Hospitalization
Assertive Community Treatment Program
Mobile Crisis Management
Mental Health - Day Treatment - Child
Developmental Therapy Service Professional
x
x
AMH
AMH
ASA
ASA
ASA
ADD
CMH
AMI - Adult AMVET - ASCDR - ASTER - ASWOM - ADSN - CMSED with Mental Veterans Injecting Adult SUD Adult SUD Adult IDD Child with
Illness and their
Drug
Treatment Women
Serious
Families User/Comm Engagement
Emotional
unicable /Recovery
Disturbance
Disease
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
CSA
CDD
CSSAD - CDSN Child with Child IDD
Substance
Use
Disorder
x
x
x
x
x
x
x
x
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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Concurrency Table
AMI
ASTER
ASCDR
ASWOM
CMSED
CSSAD
ADSN
CDSN
GAP
AMVET
X
AMI
X
ASTER ASCDR ASWOM CMSED CSSAD
ADSN
CDSN
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
GAP
X
X
X
X
X
X
X
X
X
X
AMVET
X
X
X
X
X
X
X
X
X
X
Prohibit concurrent eligibility within the LME
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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
FY15 Hierarchy
Benefit Plan
Abbreviation/
Code
DMHAD
ASCDR
ASWOM
CMSED
AMI
CDSN
ADSN
CSSAD
ASTER
AMVET
GAP
FY15
Benefit Plan Description
Hierarchy
NC Division of MH/DD/SA Services
1
Adult SA IV Drug Communicable Disease Risk
8
Adult SA Women
9
Child with Serious Emotional Disturbance
12
Adult with Mental Illness
13
Child with Developmental Disability
16
Adult with Developmental Disability
17
Child with SA Disorder
19
Adult SA Treatment Engagement and Recovery
20
Adult MH Veteran and Family
21
Generic Assessment Payment
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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Next
• How to use the Diagnosis Array workbook
• Q&A
• Policy questions regarding these changes should
be directed to Spencer Clark at
spencer.clark@dhhs.nc.gov.
• Technical questions should be emailed to
NCTracks.qanda@lists.ncmail.net.
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