Parity & the CO Dept. of Health Care Policy & Financing
Our Requests to the State:
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1. With respect to Assertive Community Treatment (ACT) & Parity: the "ASK" is really for a specific "reasonable medical necessity tool" or "eligibility criteria" and the Table does go into that. 2. With respect to An Intensive MI Quality Improvement Program. This does focus some on ACT, although not exclusively. The Quality Improvement Program could be funded through Medicaid Managed Care - & we cite the provision in the Code of Federal Regulations dealing with Quality Improvement Projects. It could also be funded through a grant and might be something that the Equitas Foundation or others might be interested in. We've Requested That The State Respond by Thurs. Feb. 22, 2018. |
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CO Medicaid Director Gretchen Hammer Responding to Request for "Medical Necessity" for ACT
The passage below provided by CO Medicaid Director Gretchen Hammer really goes to the "QUALITY" of Assertive Community Treatment Services which have been a big issue nationally. So Fidelity to the Model is important.
Further, it appears that providers could theoretically provide "Assertive Community Treatment" under Medicaid's general definition of "reasonable medical necessity." AND some people might say --- "Hey, that's what you want, isn't it?
* Nursing Homes, and
* The Mental Health Institutes
4. Further, we really do need to "flesh out" eligibility or reasonable medical necessity for Assertive
Community Treatment so that we are all on the same page.
5. Finally, "Nothing About Us, Without Us." The provision of Assertive Community Treatment is pretty
controversial both in the National Mental Health Community and the Colorado Mental Health
Community. It is vital that people with "lived experience of mental illness" be a BIG part of any oversight
of this program. Further, ACT has to be personalized by and with the individual and self-directed as
much as possible.
Further, it appears that providers could theoretically provide "Assertive Community Treatment" under Medicaid's general definition of "reasonable medical necessity." AND some people might say --- "Hey, that's what you want, isn't it?
- Well, largely yes -- BUT the BARRIERS facing the State, providers, and individuals in accessing sufficient QUANTITY of Assertive Community Treatment Slots is pretty daunting. We may very well need several thousand more slots than what Colorado has historically provided.
- Further, this is an extremely administratively complicated treatment/service to provide because it is provided with the use of a TEAM that is available 24/7, 365 days a year.
- So we think there is a great need to get a handle on how many people actually do need this service. Some likely venues are:
* Nursing Homes, and
* The Mental Health Institutes
4. Further, we really do need to "flesh out" eligibility or reasonable medical necessity for Assertive
Community Treatment so that we are all on the same page.
5. Finally, "Nothing About Us, Without Us." The provision of Assertive Community Treatment is pretty
controversial both in the National Mental Health Community and the Colorado Mental Health
Community. It is vital that people with "lived experience of mental illness" be a BIG part of any oversight
of this program. Further, ACT has to be personalized by and with the individual and self-directed as
much as possible.
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From Gretchen Hammer, Colorado's Medicaid Director:
Hi Val, There are a few components to your request about the definition of medical necessity. Below I have provided you with some information about how Assertive Community Treatment is defined by the Office of Behavioral Health and Medicaid. ACT is a defined service provided by the Community Mental Health Centers. The Office of Behavioral Health contracts with the Community Mental Health Centers and this the language they use to describe the requirements around how community mental health centers and the fidelity to the ACT model. |
Medicaid can’t be billed for an ACT service unless the provide has a minimum “good fidelity” score from the Office of Behavioral Health. This ensures that the services that are delivered are high quality and with high fidelity to the model.
The Behavioral Health Organizations are able to make a medical necessity determination for ACT, like all other BHO services. Their requirements for medical necessity determinations are in their contracts. The specific language is:
2.2.10. The Contractor may place appropriate limits on a service:
2.2.10.1. On the basis of criteria applied under the Medicaid State Plan, such as medical necessity.
2.2.10.1.1. All medical necessity determinations must utilize the medical necessity criteria defined in 10 CCR 2505-10 8.076.
The rule was recently updated by the Medical Services Board, the rule making authority for the Department. You can find the current rule on the Secretary of State website.
Orchid's Take: Most States employing a "reasonable medical necessity" determination for ACT specifically define it in Statute or regulation -- not under a general definition of reasonable medical necessity. That may be too vague and many providers likely need additional guidance.
What Colorado is really lacking is a definition for "reasonable medical necessity" for ACT.
And how does this affect CAPITATION RATES?
The Behavioral Health Organizations are able to make a medical necessity determination for ACT, like all other BHO services. Their requirements for medical necessity determinations are in their contracts. The specific language is:
2.2.10. The Contractor may place appropriate limits on a service:
2.2.10.1. On the basis of criteria applied under the Medicaid State Plan, such as medical necessity.
2.2.10.1.1. All medical necessity determinations must utilize the medical necessity criteria defined in 10 CCR 2505-10 8.076.
The rule was recently updated by the Medical Services Board, the rule making authority for the Department. You can find the current rule on the Secretary of State website.
Orchid's Take: Most States employing a "reasonable medical necessity" determination for ACT specifically define it in Statute or regulation -- not under a general definition of reasonable medical necessity. That may be too vague and many providers likely need additional guidance.
What Colorado is really lacking is a definition for "reasonable medical necessity" for ACT.
And how does this affect CAPITATION RATES?