Inpatient services for persons under 21


AZ | AZBH | CT | DE | FL | FLMH | HI | HIBH | IL | IN | IABH | MD | MA | MABH | MN
MO | NEBH | NH | NJ | NM | ND | OH | ORMH | PA | PABH | RI | TX | UTMH | VA | WA | WV

AZ

“2.  BEHAVIORAL HEALTH SERVICES...
Covered services include: ...
a. Inpatient services (Title XXI limited to 30 days per contract year)”  Arizona Contract, page 16.

AZBH

“SCOPE OF SERVICES...
Eligibility...
Covered services include...
i. Inpatient Psychiatric Facilities for persons under 21 years of age
j.  Institutions for Mental Diseases (under 21 years of age and 65 years and older)...

Title XXI (KidsCare) Limitations:  Title XXI covered services are subject to the following limitations for each contract year: ...
a. Inpatient behavioral health services provided in an inpatient psychiatric facility for persons under 21 years of age are limited to 30 days for each contract year, for Title XXI members age 18 and under.  Inpatient substance abuse services when combined with inpatient mental health services shall not exceed 30 days for each contract year.  Professional services of a psychiatrist, certified psychiatric nurse practitioner, physician assistant or psychologist provided in an inpatient setting may be billed separately and are not counted toward the annual day or visit limitations…”  Arizona Behavioral Health Contract, pages 10-11.

“Inpatient Psychiatric Facility for Individuals Under Age 21
Description of Service:
Services provided in an Inpatient Psychiatric Facility for Individuals Under Age 21 must be provided under the direction of a physician and include active treatment implemented as a result of the service plan developed.  The service plan must include an integrated program of therapies, activities, and experiences designed to meet the treatment objectives for the member.  A facility with more than 16 beds is considered an IMD, please refer to Service Description for IMDs these facilities.  (42 CFR 441.154 to 156, 456.180).

Service Limitations: ...
2.  Total inpatient behavioral health/substance abuse services provided to Title XXI (KidsCare) members are limited to 30 days per contract year (October 1 to September 30).  The 30 day limitation is cumulative and includes any emergency inpatient days provided by a health plan or other provider…
6.  Bed Hold Days are not a covered service for Title XXI (KidsCare) members.”  Arizona Behavioral Health  Contract, BHS Guide, page 2.

CT

“3.18  Special Services for Children
3.18-1  Discharge Planning Process and Inpatient Psychiatric Hospital Reinsurance for Children...
b.  The following provisions of this Section shall apply to all new admissions of children and adolescents 18 years of age and younger in qualified institutions.

1.  Reinsurance for Administratively Necessary Days
On a limited basis, the MCO may authorize the admission of a child to a qualified institution for a one-day evaluation...
2.  Reinsurance for Medically Necessary Days...
For the purpose of this section, a medically necessary admission to inpatient psychiatric care for children will be defined to include those admissions which are court ordered, provided that there is consultation with the plan prior to the order regarding the appropriate level and setting for the care…”  Connecticut Contract, pages 29-30.

“SUMMARY DESCRIPTION OF BENEFITS
A.  Covered Services Included in the Capitation Payment
1...
c.  Mental health and substance abuse services in a general hospital psychiatric unit are covered -regardless of the age of the individual.
2.  Psychiatric (mental health/substance abuse) Facility Inpatient Care
a.  Medically necessary psychiatric hospital care, procedures, and services as covered under DSS policy, and regulation.
b.  Some psychiatric hospitals may qualify as an Institution for Mental Diseases (IMD).  An IMD is defined as a facility of more than sixteen (16) beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases.

Such medically necessary care is only covered for individuals under age 21 and 65 years of age or older.  These services for individuals aged 21 through 64 are noncovered services…”  Connecticut Contract, Appendix A, page 3.

DE

“3.1  Describe the methods of delivery of the child health assistance using Title XXI funds to target low-income children:
(Section 2102(a)(4)) Delaware SCHIP (SCHIP) program is targeted to children under age 19 with income at or below 200% of the Federal Poverty Level (FPL).  The service package will include all of those basic benefit services provided under the State’s Diamond State Health Plan (DSHP) (as it was structured during 1998) through the fully capitated managed care organizations (MCOs) participating with the DSHP... They will also receive 31 days of mental health and substance abuse treatment services (any treatment modality) in a calendar year in addition to the basic MCO benefit of inpatient care, children will become eligible for Medicaid long-term care services.  Thus the SCHIP program will provide very high quality mental health and substance abuse coverage - coverage which is better by far than most private sector coverage.  Services will be provided statewide with no variations based on geography…”  Delaware RFP, Appendix A (SCHIP), page A.7.

“6.2  The state elects to provide the following forms of coverage to children:  (Check all that apply.  If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a))

The following services marked with an ‘X’ are covered by the State Child Health Insurance Program as part of a basic MCO benefit package when medically necessary with exceptions/limitations noted: ...
6.2.10.  ‘X’  Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) - inpatient mental health services may be provided as a ‘wrap-around service for up to 31 days per calendar year with the limitation that the 31 days also includes any other mental health and/or substance abuse treatment services (including outpatient, residential and any other treatment modality) outside of the basic MCO benefit of 30 outpatient visits.  Children who need inpatient services beyond this will convert to Medicaid Long-Term Care...
6.2.18  ‘X’  Inpatient substance abuse treatment services and residential substance abuse treatment services  (Section 2110(a)(18)) - see note in 6.2.10…”  Delaware RFP, Appendix A (SCHIP), page A.18-A.19.

FL

“C.  Additional Medicaid Behavioral Health Care Service Requirements
The behavioral health services described below are those required by federal or state rules governing the Medicaid program, as prescribed by the Medicaid Coverage and Limitations Handbooks...
1. Inpatient Mental Health Hospital Services
a. For Child/adolescent members (members under 21 years of age), the plan shall be responsible for the provision of up to 365 days of behavioral health hospital inpatient case of each state fiscal year...”  Florida Contract, page 167.

FLMH

“2.2 General Service Requirements
A.  The prepaid mental health plan contractor will provide a full range of mental health care service categories authorized under the state Medicaid plan and the state mental health program plan, as follows.
1. Inpatient hospital care for psychiatric conditions...”  Florida Mental Health RFP, page 21.

“2.3 Medicaid Service Requirements...
A.  Inpatient Hospital Services...
Inpatient hospital services include but are not limited to medical supplies, diagnostic and therapeutic services, use of facilities, drugs and biologicals, room and board, nursing care and all supplies and equipment necessary to provide adequate care as specified in the Medicaid Hospital Provider Handbook.
Inpatient Services Medicaid prepaid mental health plan policy requirements are as follows: ...
2. For all child/adolescent enrollees (enrollees under 21 years of age), the contractor shall be responsible for the provision of up to 365 days of mental health hospital inpatient care for each year.”  Florida Mental Health RFP, pages 22-23.

“2.4 Additional Service Requirements...
C.  Evaluation and Treatment Services for Children...
3. ...The state will retain responsibility for payment for all mental health services (with the exception of inpatient hospitalization... provided to children in therapeutic foster care and residential treatment...”  Florida Mental Health RFP, page 26.

“The following is a summary list of the services which must be provided under the prepaid mental health plan contract...  Mandatory Services...
e.  Inpatient Hospital Services...”  Florida Mental Health RFP, page 93.

HI

“30.710 Medical Services ...
The services include all medically necessary and preventive services.  The health plan shall provide, at a minimum, whatever services are currently covered by the Hawaii Medicaid program...
* Acute inpatient hospital services for... psychiatric…” Hawaii RFP, pages 16-17.

“30.720  Behavioral Health...
* Coverage will be limited to... thirty days of hospitalization per benefit year.
* Each day of inpatient hospital services may be exchanged for two days of non-hospital residential services, two days of partial hospitalization services, or two days of day treatment of two days of intensive outpatient services,  Detoxification, whether provided in a hospital or in a non-hospital facility, shall be considered part of the inpatient benefit limit.
* Diagnosis and treatment of substance abuse will be included in the inpatient... benefits for psychiatric treatment...

The health plan shall be responsible for providing comprehensive behavioral health services up to the benefit limits including:
* Twenty-four hour care for acute psychiatric illnesses including:
- Room and board
- Nursing care
- Medical supplies and equipment
- Diagnostic services
- Physician services
- Other practitioner services as needed
- Other medically necessary services…” Hawaii RFP, pages 20-21.

HIBH

“20.720  Severely Emotionally Disturbed (DSED)...
The BHMC plan shall provide to children and youth determined to be SED, a full range of behavioral health services including inpatient…”  Hawaii Behavioral Health RFP, page 9.

“Residential Treatment for Children and Adolescents - services providing a therapeutically planned group living situation delivered on a 24 hour basis for individuals under age 18.  This service represents an alternative to hospitalization, most commonly a step-down from inpatient behavioral health services.”  Hawaii Behavioral Health RFP, page A9.

IL

“(b)  Covered Services...
(2)  Medically Necessary Covered Services
The following services and benefits shall be included as Covered Services under this Contract and will be provided to Beneficiaries whenever medically necessary: ...
* Inpatient hospital services (including dental hospitalization and acute medical detoxification);
* Inpatient psychiatric care…”  Illinois HMO Contract, page 19.

IN

“3.1.3  Medicaid Covered Services
The Indiana Medicaid program covers the following services for all eligible recipients.  The specific services covered under the managed care initiative are specified in Section 4.4 of this RFP...
* Psychiatric hospital services for individuals under age 21 and individuals age 65 or older.
* Psychiatric hospital services for individuals between age 21 and 65 in psychiatric facilities of sixteen beds or less…”
Indiana RFP, pages 3-3 - 3-5.

“CHIP Benefit Package
Service:  Outpatient mental health/substance abuse services+
Indiana Medicaid Benefits:  Includes mental health services provided by physicians, psychiatric wings of acute care hospitals, outpatient mental health facilities and psychologists endorsed as Health Services Providers in Psychology.  Office visits limited to a maximum of 4 per month or 20 per year per recipient without prior approval.
CHIP Benefit Package:  Covers outpatient mental health/substance abuse services when the services are medically necessary for the diagnosis or treatment of the recipient’s condition except when provided in an institution for mental diseases. Office visits limited to a maximum of 30 per year per recipient without prior approval to a maximum of 50 visits per year.

Service:  Inpatient mental health/substance abuse services**+
Indiana Medicaid Benefits:  Each patient admitted must have an individually developed plan of care developed by the physician and interdisciplinary team.  Plan of care must be reviewed and updated every thirty days by the interdisciplinary team.

Recertification is required every 60 days.
CHIP Benefit Package:  Inpatient mental health/substance abuse services are covered when the services are medically necessary for the diagnosis or treatment of the recipient’s condition except when they are provided in an institution for mental diseases with more than 16 beds.
**Prior Approval Always Required
*Prior Approval Required Under Certain Circumstances
+Federally Required CHIP Benefits.”  Indiana SCHIP Amendment, Attachment C-1, page 4.

“CHIP Benefit Package
Service:  Outpatient mental health/substance abuse services+
Indiana Medicaid Benefits:  Includes mental health services provided by physicians, psychiatric wings of acute care hospitals, outpatient mental health facilities and psychologists endorsed as Health Services Providers in Psychology.  Office visits limited to a maximum of 4 per month or 20 per year per recipient without prior approval.
CHIP Benefit Package:  Covers outpatient mental health/substance abuse services when the services are medically necessary for the diagnosis or treatment of the recipient’s condition except when provided in an institution for mental diseases. Office visits limited to a maximum of 30 per year per recipient without prior approval to a maximum of 50 visits per year.
**Prior Approval Always Required
*Prior Approval Required Under Certain Circumstances
+Federally Required CHIP Benefits.”  Indiana SCHIP Amendment, Attachment C-1, page 4.

IABH

“Medically Managed Inpatient Treatment:  Addiction and chemical dependency treatment in an acute care hospital setting.  Patient’s medical condition is such that a physical examination by a physician is required within twenty-four hours of admission.  This setting provides twenty-four hour medical monitoring of treatment and detoxification services; and 50 or more hours of service per week are provided.

Medically Monitored Residential:  Addiction and chemical dependency treatment in a residential or a non acute care hospital setting.  Patients medical condition is such that a physical examination by a physician is required within twenty-four hours of admission.  The setting provides twenty-four hour medical monitoring of treatment and detoxification and 50 or more hours of service per week.”  Iowa Behavioral Health Contract, page 49.

“ATTACHMENT ON MENTAL HEALTH SERVICES
Covered Mental Health Services...
* Services in state Mental Health Institutes for enrollees under the age of 21 or through the age of 22 if the enrollee is hospitalized on the enrollee’s 21st birthday…”  Iowa Behavioral Health Contract, page 79.

“Other Required Mental Health Services...
Services at a State Mental Health Institute for persons under the age 21:  State Mental Health Institutes shall be part of the Contractor’s provider panel.  The Contractor shall reimburse all inpatient treatment for persons under the age of 21 at state Mental Health Institute which falls within the Contractor’s Utilization Management Guidelines.  The Contractor also shall reimburse at least five days of inpatient services, or the duration of that  evaluation period if less than five days is required, when an Iowa Plan enrollees under the age of 21 is court-ordered for an inpatient mental health evaluation.  The Contractor may establish policies to limit reimbursement to no more than one evaluation per inpatient episode.”  Iowa Behavioral Health Contract, pages 81-82.

“III.  SPECIAL CONSIDERATIONS FOR SUBSTANCE ABUSE SERVICES...
2. Psychiatric Medical Institution For Children (PMIC)
Criteria for service necessity for PMIC substance abuse treatment facilities is established by DHS.  Contractor is required to provide assurance to DHS that Medicaid enrollees or potential Medicaid enrollees entering substance abuse licensed PMI’s meet the criteria.

Persons admitted to a substance abuse licensed PMIUC with a primary diagnosis of substance abuse typically present a need for concurrent substance abuse treatment and mental healthcare which is part of the nature of the care provided by a substance abuse licensed PMIC.  The need for substance abuse PMIC services is determined by the person’s admitting diagnosis and, once determined, is not altered by a change in diagnosis as long as treatment at a substance abuse licensed PMIC remains appropriate and meets the client’s needs.  Because many persons entering PMICs apply for and gain Medicaid eligibility and enrollment upon or after admission, Contractor must manage all new admissions in the same manner as if that person were a Medicaid enrollee at the date of admission.

Contractor shall serve Medicaid beneficiaries residing in substance abuse PMICs as enrollees even for months of retroactive eligibility (prior to month of application) and when eligible in coverage groups not typically enrolled.”  Iowa Behavioral Health Contract, page 86.

MD

“10.09.67.10...
.10  Benefits-Substance Abuse Treatment Services.
A.  An MCO shall provide to its enrollees medically necessary and appropriate comprehensive substance abuse treatment services in accordance with the standards set forth in COMAR 10.09.65.11-.11-2, including but not limited to:
(4)  For enrollees younger than 21 years old, residential substance abuse treatment in an intermediate care facility-alcoholic (ICF-A), with a length of stay determined by medical necessity…”  Maryland COMAR 10.09.67.10.

MA

“Section 2.12  Behavioral Health Program Services...
M.  Children and Adolescents BH Services
The Contractor shall:
1. Design by March 1, 1999, a plan to ensure that, at a minimum, the following BH Services for children and adolescents are available:
a. Pre-residential stepdown programs for BH Services between BH Inpatient hospital level of care and 24 hour residential level of care…”  Massachusetts Contract, pages 68-88.

MABH

“5.10 Children and Adolescent Services The Contractor shall:
5.10.01 Design and implement a plan within six months after the Full Service Start Date to ensure that, at a minimum, the following services for children and adolescents are available:
a. pre-residential step-down programs between inpatient hospital level of care and 24 hour residential level of care...
c. Crisis Stabilization on-site at DSS residential programs…”  Massachusetts MH/SAP Contract, Appendix B, page 47.

“APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
B.  Diversionary Services...
9.  Residential Mental Health Treatment for Children and Adolescents - shall mean services providing a therapeutically planned group living situation delivered on a 24 hour basis for individuals under 18 years of age. This service represents an alternative to hospitalization, most commonly as a step- down from Inpatient Mental Health Services.
10.  Residential substance Abuse Treatment - shall mean short-term twenty-four hour therapeutically planned treatment and learning situation for adults or adolescents which provides continuity of care after level III Detoxification for individuals engaging in recovery.”  Massachusetts MH/SAP Contract, Appendix C, pages 1, 3.

“II. DMH Covered Services
A. Inpatient Services - shall mean twenty-four hour services which provide medical intervention for mental health.
1. Inpatient Mental Health Services - shall mean hospital services to stabilize an acute psychiatric condition which: 1) has a relatively sudden onset, 2) a short, severe course, 3) poses a significant danger to self or other, and/ or 4) has resulted in marked psychosocial dysfunction and/or grave mental disability.”  Massachusetts MH/SAP Contract, Appendix C, page 7.

MN

“Section 2.23. Inpatient Hospitalization includes inpatient medical, mental health and chemical dependency services.”
Minnesota Contract, page 12.

“Section 6.1. MA and MinnesotaCare/MA Covered Services. The HEALTH PLAN shall provide, or arrange to have provided to MA and MinnesotaCare/MA Enrollees comprehensive preventive, diagnostic, therapeutic and rehabilitative health care services as defined in Minnesota Statutes… These services shall include but are not limited to, the following…

Section 6.1.16.  Mental Health Services...
A.  General Mental Health Services...The HEALTH PLAN must ensure that the following services are available to its Enrollees: ...
5)  Inpatient and outpatient treatment...”  Minnesota Contract, pages 48-49, 55.

MO

“Mental health and substance abuse services are included in the comprehensive benefit package as follows: ...
4)  Services shall include, but not be limited to:
* Inpatient hospitalization, when provided by acute hospital, private or state psychiatric hospital...
* Alternative services which are reasonable, cost effective and related to the individual’s treatment plan…”  Missouri RFP, page 51.

“Behavioral Services for Category of Aid 4 ‘Other Medicaid Children’:  For children covered under the MC+ health plan within this group, the following behavioral health services, if medically necessary, will not be the financial responsibility of the health plan and will be provided: a.  Inpatient Mental Health Services:  Services will be any psychiatric stay in an acute care hospital or in a private or State psychiatric hospital.  The health plan primary care provider and the child’s caseworker will be required to coordinate services...”  Missouri RFP, page 63.

“Behavioral health services (including inpatient…children in Category of Aid 4 (primary children in state custody) are not the financial responsibility of the health plan and will be reimbursed to Medicaid-enrolled providers on a fee-for-service basis…” Missouri RFP, Attachment Five.

NEBH

“4.1  Applicable Definitions: The following definitions apply under this contract: ...
4.1.26  The term ‘Mental Health and Substance Abuse (MH/SA) Package’ means the following MH/SA services that represent a minimum benefits package that must be provided by the Prepaid Health Plan to NHC clients who have a mental health or substance abuse condition: ...
(b)  MH/SA Services for Children and Adolescents Age 20 and Younger (See 471 NAC 32-000), including: ...
(7)   Acute Inpatient Hospitalization Services…”  Nebraska Behavioral Health Contract, pages 6 and 9.

“11.2  Governing NHC Regulations: ...
MH/SA services are provided by the Prepaid Health Plan (PHP) for all NHC clients.  The MH/SA Package includes the following services: ...
(b)  MH/SA Services for Children and Adolescents Age 20 and Younger (See 471 NAC 32-000), including: ...
(7) Acute Inpatient Hospitalization Services;
(8) Inpatient Services in Institutions for Mental Disease (IMDs)…”   Nebraska Behavioral Health Contract, page 51.

“11.55.4  History and Physical (H&P) Exams for Inpatient Admissions for MH/SA Services: ...
Inpatient MH/SA services provided to clients participating in the MH/SA component of the NHC in a freestanding or hospital-based residential treatment center (RTC) or treatment group home (TGH) are considered inpatient services and are the responsibility of the PHP.  H&Ps provided to NHC clients for these allowable services are not the responsibility of the medical/surgical plan, if the client is participating in the medical/surgical component of the NHC.”  Nebraska Behavioral Health Contract, pages 68-69.

NH

“Covered Services
I. Covered Services-General...
I. Mental Health/Substance Abuse Services...
2. Inpatient Services:
Contractor will cover individuals under age twenty-one (21) and over age sixty-five (65) years up to thirty (30) days of inpatient care in a private mental health facility. Care may be provided in a general acute care Hospital for all ages who meet the Plan’s medical necessity criteria Should an Enrollee require partial hospitalization, this service will be covered under this clause with two (2) days of partial hospitalization equaling one (1) full day of inpatient care. Contractor determines medical necessity and the appropriate facility for treatment.”  New Hampshire General Service Agreement, Exhibit A.3., page 4.

NJ

“ARTICLE 10
COVERED HEALTH CARE SERVICES
10.1 For enrollees who are Medicaid-eligible through Title XIX or the NJ KidCare Plan A program, the contractor shall provide or shall arrange to have provided comprehensive, preventive, diagnostic, rehabilitative, and therapeutic health care services to enrollees that include all services that Medicaid recipients are entitled to receive pursuant to Medicaid, subject to any limitations and/or excluded services as specified in Appendix A of this contract. DMAHS shall assure the continued availability and accessibility of Medicaid covered services not covered under this contract. All services provided shall be in accordance with the New Jersey State Plan for Medical Assistance, the New Jersey Medicaid Managed Care Plan, and all applicable statutes, rules, and regulations.

10.1.1 For beneficiaries eligible solely through NJ KidCare Plan B and Plan C, the contractor shall provide the same managed care services and products provided to enrollees who are eligible through Title XIX. However, non-HMO covered services (i.e., services that continue to be provided fee-for-service) will be limited to certain services for the NJ KidCare Plan B and C populations as indicated in Appendix A.

10.1.2 For beneficiaries eligible solely through NJ KidCare Plan D, the contractor shall provide the managed care services and products as delineated in Appendix S. Non-HMO covered services (i.e., services that will be provided fee-for-service by the Division of Medical Assistance and Health Services) will be limited to the services delineated in Appendix S.

10.2 The contractor hereby agrees that no distinctions shall be made with regard to the provision of services to Medicaid enrollees and the provision of services provided to the contractor’s other non-Medicaid members unless required by this contract.

10.3  The scope of services to which an enrollee is entitled from the contractor, while deemed eligible for enrollment in the contractor’s plan, is those services included in the benefits package. The remaining services to which enrollees are entitled under the Medicaid program but are not included in the contractor’s benefits package will continue to be covered by Medicaid under its fee-for-service program.”  New Jersey Contract, page 51.

“APPENDIX S
NJ KIDCARE - PLAN D
BENEFITS PACKAGE-INCLUSIONS AND EXCLUSIONS...
BEHAVIORAL HEALTH FEE-FOR-SERVICE BENEFITS
1.  Inpatient hospital services, including psychiatric hospitals, limited to 35 days per year…”  New Jersey Contract, Appendix S, pages 233-236.

NM

“2.D.29.a  Inpatient Hospital Services:
The benefit package includes inpatient hospital psychiatric services provided in general hospital units and/or PPS-exempt Units in a general hospital as set forth in the Medical Assistance Division Program Manual Section MAD-721, HOSPITAL SERVICES,” New Mexico Contract, page 42.

“22.D.30  Behavioral Health Services Included Only in the Benefit Package for Children: ...
2.D.30.a  Inpatient Hospitalization in Free Standing Psychiatric Hospitals
The benefit package includes inpatient services in free standing psychiatric hospitals as set forth in the Medical Assistance Division Program Manual Section MAD-742.1, INPATIENT PSYCHIATRIC CARE IN FREESTANDING PSYCHIATRIC HOSPITALS.” New Mexico Contract, pages 42-43.

ND

“ATTACHMENT L:  COVERED SERVICES...
13.  Mental Health Services - includes (1) inpatient psychiatric services provided in district part units of acute care hospitals, (2) institutions for mental diseases including the State Hospital for individuals under 22 years of age…”  North Dakota Contract, Attachment L, pages 1-2.

OH

“D.2.  Clarifications...
1. Mental Health Services...
MCPs must provide covered services through inpatient facilities when medically necessary. The MCP is not responsible for payment of claims for inpatient psychiatric care received in state-operated psychiatric facilities.
MCPs must advise enrollees via the member handbook of the ability to self-refer to mental health services offered through community mental health centers (CMHCs). The community Medicaid-covered services include... inpatient psychiatric care in psychiatric hospitals (for persons under 22 and 65 and older). MCPs may refer enrollees to eligible providers of community mental health services…
2. Substance Abuse Services
MCPs are responsible for ensuring that enrollees receive medically necessary inpatient detoxification services…”  Ohio RFP, page 13.

ORMH

“f.  Acute Inpatient Hospital  Psychiatric Care
(1) Contractor shall maintain agreements with local and regional hospitals to ensure provisions of emergency and non emergency hospitalization for OMAP Members with mental disorders which require Acute Inpatient Psychiatric Care...
(2) Contractor shall cover the cost of Acute Inpatient Psychiatric Care for OMAP Members who do not meet the criteria for Long Term Psychiatric Care.”  Oregon Mental Health Contract, page 16.

“DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
JCAHO Psychiatric Residential Program:  A program which provides non-emergency inpatient (residential) psychiatric services for children under age 21 in residential facilities which are licensed by SOSCF and accredited by the JCAHO.  These programs must meet DARTS standards regarding staffing credentials and staffing patterns, the integration of education and treatment, and Family focused, community based treatment.”  Oregon Mental Health Contract, Appendix K, pages K1, K11.

PA

“H.  Coordination with Out-of-Plan Services...
9. Behavioral Health Services...
b. Behavioral Health Services Excluded from HealthChoices HMO Covered Services

The following services are not the responsibility of the HMO, under the HealthChoices Program.
* The behavioral health contractor (MCO) will provide access to diagnostic, assessment, referral, and treatment services for members for the following benefits: ...
* Residential services for children (JCAHO accredited and non-JCAHO)…”  Pennsylvania RFP, pages 51-56.

PABH

“2)  Service Categories for Rate Categories 1-7
For rate categories 1 through 7, there are 11 categories of service for which annualized utilization frequencies must be estimated.  Specifically: ...
a) Inpatient Psychiatric.  The anticipated utilization should be expressed as the average number of hospital inpatient days expected per 1,000 members...
b) The anticipated utilization should be expressed as the average number of hospital inpatient days expected per 1,000 members...”  Pennsylvania Behavioral Health RFP, page 33.

“D.  Tasks
1. In-Plan Services...
a. The MCO will provide timely access to diagnostic, assessment, referral, and treatment services for members for the following benefits: ...
1) inpatient psychiatric hospital services, except when provided in a state mental hospital;
2) inpatient drug and alcohol detoxification…
4) inpatient drug and alcohol rehabilitation...
8) residential treatment services for children and adolescents (JCAHO accredited and non-JCAHO)...”  Pennsylvania Behavioral Health RFP, pages 48-49.

RI

“2.06.02.01  General...
The comprehensive benefit package includes… mental health and substance abuse services…”  Rhode Island RFP, page 21.

“SCHEDULE OF IN-PLAN BENEFITS...
Mental Health and Substance Abuse Services- Inpatient
Both short and long term treatment covered as needed, base on medical necessity.  (Butler Hospital may be used for services).

Includes day treatment, partial hospitalization, and residential treatment, except for residential treatment for children ordered by DCYF, and except for residential substance abuse treatment for children age 13 to 17.  Covered residential treatment includes therapeutic services but does not include room and board, except in a facility accredited by the Joint Commission on accreditation of Healthcare Organizations (‘JCAHO’).  Covered services subject to limitations described in attachment B…”  Rhode Island RFP, Attachment A. pages 1, 3.

“ATTACHMENT A
SCHEDULE OF IN-PLAN BENEFITS...
SERVICE

Mental Health and Substance Abuse Services-Inpatient
SCOPE OF BENEFIT (ANNUAL)
Both short-and long-term treatment covered as needed, based on medical necessity.  (Butler Hospital may be used for services).  Includes day treatment, partial hospitalization, and residential treatment, except for residential treatment for children ordered by DCYF, and except for residential substance abuse treatment for children age 13 to 17.  Covered residential treatment includes therapeutic services but does not include room and board, except in a facility accredited by the Joint Commission on accreditation of Healthcare Organizations (‘JCAHO’).  Covered services subject to limitations described in Attachment B.”  Rhode Island RFP, Attachment A, pages 1, 3.

“ATTACHMENT B
SCHEDULE OF OUT-OF-PLAN BENEFITS
These benefits are not included in the capitated benefit and are not the responsibility of the Health Plan to provide or arrange. The Health Plan is expected to refer to and coordinate with these services as appropriate.  These Services will be provided by existing Medicaid-approved providers who will be reimbursed directly by the State on a fee-for -service or contractual basis…
Seriously and Persistently Mentally Ill (SPMI) Adults and Seriously Emotionally Disturbed (SED) Children...  These individuals will have all out-of-plan benefits listed above in ‘All RIte Care Enrollees’ and., in addition will receive the following mental health services out-of-plan: ...
* Acute psychiatric inpatient hospitalization...
* Inpatient psychiatric facility services for individuals under age 21 or 22 if confined beyond 21st birthday…”  Rhode Island RFP, Attachment B, pages 1, 3-4.

TX

“6.6  BEHAVIORAL HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS…
6.6.11 HMO must provide inpatient psychiatric services to Members under the age of 21 who have been ordered to receive the services by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities.
6.6.11.1 HMO cannot deny, reduce or controvert the medical necessity of any court ordered inpatient psychiatric service for Members under age 21.  Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination.”  Texas Contract, pages 38-40.

UTMH

“Article III
SCOPE OF SERVICES...
A.  Covered Services
The CONTRACTOR will provide, at a minimum, all Medically Necessary Covered Services in accordance with the scope of services in the Utah State Plan and the Utah Medicaid Mental Health Centers Provider Manual, incorporated by reference.  The manuals are available from the department upon request.  Covered services include the following services: ...
1. Inpatient psychiatric hospital services and related inpatient physician services based on the following International
Classification of Diseases: 295 through 302, 306 through 309, 311 through 314, and 316; or corresponding codes as the International Classification of Diseases is revised.”  Utah Mental Health Contract, page 4.

“B.  Clarification of Covered Services...
4. Inpatient and outpatient mental health services are Covered Services when they are Medically Necessary for the treatment of mental illness for individuals who carry a dual diagnosis of mental illness and developmental disorder/mental retardation (regardless of IQ) or organic (neurologic) disorder or substance abuse disorder...

8.  Inpatient mental health services are Covered Services for foster care children...

12.  Inpatient psychiatric services provided in free-standing psychiatric hospitals to Medicaid Enrollees under age 22 or age 65 or older are Covered Services...

14.  If the CONTRACTOR admits an Enrollee for inpatient hospital psychiatric care, the CONTRACTOR has the
responsibility for all services needed by the Enrollee during the hospital stay that are ordered by the CONTRACTOR.  Needed services include, but are not limited to diagnostic tests, pharmacy and physician services.  If diagnostic tests conducted during the inpatient stay reveal that the Enrollee’s condition is outside the scope of the CONTRACTOR’s responsibility, the CONTRACTOR  who admitted the Enrollee remains responsible for the Enrollee until the Enrollee is discharged or until responsibility, including negotiating a payment for services.  If the Enrollee is discharged and needs further services, the admitting contractor must coordinate with the other appropriate entity to ensure continued care is provided.  The CONTRACTOR and appropriate entity must work cooperatively in the best interest of the Enrollee.  The appropriate entity includes, but is not limited to an HMO...

C.  Clarification of Non-covered Services...
6.  Inpatient and outpatient mental health services for substance abuse disorders are not Covered Services under the Contract.”  Utah Mental Health Contract, pages 6-7.

VA

“28.  Psychiatric Hospitals For Medicaid Enrollees:
The Contractor shall cover all services rendered in free-standing psychiatric hospitals to enrollees up to twenty-one (21) years of age and enrollees over sixty-four (64) years of age.  Inpatient psychiatric services rendered in a psychiatric unit of a general acute care hospital shall be covered for all Medicaid eligible enrollees regardless of the age of the enrollee, as set forth in 12 VAC 30-50-100.

For all enrollees under age twenty-one (21), all inpatient admissions to a State hospital or a private free standing psychiatric hospital must be screened by the Community Services Board (CSB) serving the area in which the enrollee resides, in accordance with 42 C.F.R 441.153...

All inpatient mental health admission for individuals of any age to general acute care hospitals shall be approved by the Contractor using its own prior authorization criteria as approved by the Department or the Department’s criteria.  All inpatient psychiatric admissions for individuals under twenty-one (21) and over sixty-four (64) years of age to freestanding psychiatric facilities shall also be approved by the Contractor using its own prior authorization criteria as approved by the Department.

For CMSIP Enrollees:
Inpatient mental health services will be offered in general acute care hospitals only.  Services offered in IMDs or free standing psychiatric units are prohibited because inpatients in IMDs or free standing psychiatric units are not eligible for CMSIP.”  Virginia Contract, page 51.

WA

“EXCLUSIONS
The following services and supplies are excluded from coverage under this agreement.  This shall not be construed to prevent the Contractor from covering any of these services when the Contractor determines it is medically necessary.
SERVICES COVERED BY OTHER DIVISIONS/ADMINISTRATIONS IN THE DEPARTMENT: ...
* Mental health services purchased for all Medicaid clients by the Mental Health Division in DSHS, including… inpatient psychiatric services...

SERVICES COVERED BY MAA FEE-FOR-SERVICE OR THROUGH SELECTIVE CONTRACTS: ...
* Inpatient psychiatric professional services.”  Washington Contract, Exhibit 6, Attachment 1, pages 5-6.

WV

“MEDICAID BENEFITS COVERED UNDER FEE-FOR-SERVICE MEDICAID
The following services are excluded from HMOs’ capitation rates, but will remain covered Medicaid services for the person who are enrolled in HMOs.  The state will continue to reimburse the billing provider directly for these services on a fee-for-service basis...

MEDICAL SERVICE…/SCOPE OF BENEFITS//LIMITATION ON SERVICES
Inpatient Psychiatric Services for Individuals Under 21/Active treatment of psychiatric condition through an individual plan of care including post discharge plans for aftercare.  Service is expected to improve the recipients condition of prevent regression so the service will no longer be needed./Certification must be made prior to admission that outpatient behavioral health resources available in the community did not meet the treatment needs of the recipient  Pre-admission and continued stay prior authorization…”  West Virginia Contract, Exhibit A, page 5.

“Behavioral Health Carveout
Prior to April 1996, all behavioral health services will be provided on a pay-for-service basis.  Beginning in or after 1996, a behavioral health managed care organization (MCO) will provide behavioral health services on a capitated basis.  These behavioral health services include the following:

MEDICAL SERVICE/ SCOPE OF BENEFITS/ LIMITATION ON SERVICES
Inpatient Psychiatric Services for Individuals Under Age 21./ Active treatment of psychiatric condition through an individual plan of care including post discharge plans for aftercare.  Service is expected to improve the recipients condition or prevent regression so the service will no longer be needed./ Certification must be made prior to admission that outpatient behavioral health reworks available in the community did not meet the treatment needs of the recipient.  Pre-admission and continued stay prior authorization.”  West Virginia RFA, Appendix A, A7.