AACP Newsletter, Volume 10,
Number 3, Summer 1996
Regional Report
Pennsylvania Moves Ahead on Managed Care Program for Medicaid Recipients
About 35 percent of all MA eligible persons reside in the five-county area in southeast Pennsylvania where the managed care program, called HealthChoices, will be implemented first by the Pennsylvania Department of Public Welfare (DPW). The counties include Bucks, Chester, Delaware, Montgomery, and Philadelphia.
The Office of Mental Health, in collaboration with the Department of Health’s Office of Drug and Alcohol Programs, has worked since February on developing a request for proposals (RFP) for the mental health and substance abuse services component of DPW’s managed care program. Central to both the physical and behavioral health managed care initiatives is the integration and coordination of health services to improve accessibility, continuity, and quality of services for eligible MA recipients, while controlling each program’s rate of cost increase. County government has the first opportunity to manage the behavioral health component of the HealthChoices program.
Implementation of the managed care initiative for both physical and behavioral health services is scheduled to begin January 1, 1997. A scheduled MA recipient phase-in is planned.
A benefits consultant will perform all enrollment activities, provide marketing materials (e.g., pamphlets and brochures which the MA recipient can use to select an HMO and primary care practitioner), assist with member access to behavioral health services, and more.
The Office of Mental Health released its draft RFP for behavioral health services simultaneously with the release of the benefits consultant and physical health care requests for bids. Essential treatment services of the behavioral health RFP include:
- inpatient psychiatric hospital services, except when provided in a state mental hospital;
- inpatient drug and alcohol (D&A) detoxification;
- psychiatric partial hospitalization services;
- inpatient D&A rehabilitation;
- non-hospital residential detoxification, rehabilitation, and half way house services for D&A dependence or addiction;
- psychiatric outpatient clinic services;
- mental health and D&A rehabilitation services for children (EPSDT) wraparound);
- residential services for children (JCAHO-accredited and non JCAHO);
- outpatient D&A services, including Methadone Maintenance Clinic;
- methadone and other narcotic/opiate dependency medication therapies;
- laboratory studies ordered by behavioral health physicians;
- clozapine (Clozaril TM) and clozapine support services;
- crisis intervention with in-home capability (effective July 1,1997);
- family-based mental health services for children and adolescents;
- targeted mental health case management (intensive case management and resource coordination); and
- behavioral health rehabilitation services (EPSDT) for children and adolescents with mental retardation.
The RFP also incorporated guidelines for use in making medical necessity decisions for inpatient hospital, partial hospitalization, and outpatient psychiatric clinic services for adults, as well as criteria for child/adolescent inpatient hospital, partial hospitalization, outpatient clinic, behavioral health rehabilitation, and residential services. The Pennsylvania Psychiatric Society participated in the development of the medical necessity criteria for both adult and child/adolescent mental health services.
A public meeting for comments on the draft RFP was conducted on May 3, 1996, at Norristown State Hospital. The Office of Mental Health plans to have contracts for behavioral health services for each of the southeast area counties signed in August, 1996.
Denis J. Milke, MD
Medical Director
Pennsylvania Office of Mental Health
Reprinted with permission from the Pennsylvania Psychiatrist, July, 1996.
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