Updated Questions and Answers Regarding PAHP Program – 4/25/07

1.  Is the list of outpatient medical services an exhaustive list? Are they the only services provided by our our psychiatrists and ARNPs that KHS will compensate and are the stated rates final?

Response: The list that was previous posted as a working draft has been updated and finalized, and that updated draft is available on this site as “Updated List of Covered Services And Rates – April 2007”.

2. I see that peer support is included in the PAHP. Where would I go to find more information on exactly what kinds of peer support – if that has already been finalized. If not yet final, I would like to have an opportunity to say some things about it that I hope would be beneficial.

Response: In addition to the description of this service included at Appendix F to the PAHP contract on this site, and the outcome requirements associated with the service included in the PAHP contract, operational information about that service for Kansas will soon be available on this site.

3. The contract on page 69, section c states, "The Contractor shall identify people with high needs, initiiate ongoing treatment coordination and ensure provider treatment planning and service coordination--" Then in section d. "In order to identify Members with special mental heqalth treatment needs, the Contractor is required to identify Members who meet the state approved criteria for SPMI, or SED; OR have a dual diagnosis--" Does this indicate that people with cooccurring disorders will be considered part of the target population and, therefore be qualified for CPST, TCM etc.? If so and in that context how is dual diagnosis defined?

Response: No, it does not mean that people with co-occurring service needs are part of the mental health target population.  It does mean that specific attention will be given by both the PAHP contractor and the PIHP contractor, in close collaboration with SRS program staff setting policy direction for both programs, to meet the needs of people with co-occurring disorders in increasingly effective ways.

 4.  Explain the Medicaid cash flow of the PAHP, specifically the funding for the Rehabilitation Services; the funding for the SED/HCBS waiver and the funding for the Outpatient Services.

Response: The  PAHP will be paid a per member per month fee and will pay the providers from these payments.  The PAHP will reconcile quarterly with SRS on the payments based on a Medicaid fee schedule of services provided.

5.  What is the definition of Medical Necessity that will be used by Kansas Health Solutions, LLC to determine services?

Response: When determining the medical necessity for mental health services, the Contractor shall:

• A. Use Kansas definition of medical necessity when determining the need for T-XIX State Plan, 1915 (b) 3, and HCBS SED Waiver mental health services.
  
  
• B.  Use the SRS-approved functional assessment tools for determining the need for Community Based Rehabilitation Services, 1915(b)3 services, and HCBS SED Waiver mental health services
  
  
• C.  Use the Kansas HCBS SED Waiver clinical eligibility criteria when determining the need for HCBS SED Waiver services.

MEDICAL NECESSITY means that a clinical intervention for an otherwise covered category of service, is not specifically excluded from coverage, and is medically necessary, according to all of the following criteria:

• Authority. The clinical intervention is recommended by the treating clinician and is determined to be necessary by the Secretary or the Secretary's designee.
  
  
• Purpose. The clinical intervention has the purpose of treating a medical condition/mental illness.
  
  
• Scope. The clinical intervention provides the most appropriate supply or level of service, considering potential benefits and harms to the client.
  
  
• Evidence. The clinical intervention is known to be effective in improving health outcomes. The scientific evidence for each existing intervention shall be considered first and, to the extent possible, shall be the basis for determinations of medical necessity. If no scientific evidence is available, professional standards of care shall be considered. If professional standards of care do not exist, or are outdated or contradictory, decisions about existing interventions shall be based on expert opinion. Coverage of existing interventions shall not be denied solely on the basis that there is an absence of conclusive scientific evidence. Existing interventions may be deemed to meet this regulation's definition of medical necessity in the absence of scientific evidence if there is a strong consensus of effectiveness and benefit expressed through up-to-date and consistent professional standards of care or, in the absence of those standards, convincing expert opinion.
  
• Value. The clinical intervention is cost-effective for this condition compared to alternative interventions, including no intervention. The term “Cost-effective'' shall not necessarily be construed to mean lowest price. An intervention may be clinically indicated and yet not be a covered benefit or meet the definition of medical necessity. Interventions that do not meet the definition of medical necessity may be covered at the choice of the Secretary or the Secretary's designee. An intervention shall be considered cost-effective if the benefits and harms relative to costs represent an economically efficient use of resources for members with this condition. In the application of this criterion to an individual case, the characteristics of the individual member shall be determinative. “Medical necessity in psychiatric situations'' means that there is medical documentation that indicates that the person could be harmful to himself or herself or others if not under psychiatric treatment or that the person is disoriented in time, place, or person. 

6.  What are the anticipated changes in how the CMHC’s will serve the targeted populations, (SPMI and SED clients) when the new Medicaid State Plan is implemented?

Response: There is no expected change to how the CMHC’s will  serve these targeted populations, other then if they don’t have the capacity to serve them  then they can contract out for other providers or they can  open their area up to the PAHP to contract with providers to meet the demand.

Here is a summary of how SRS expects that the various categories of services will be provided:

 Reserved to CMHCs unless need for other providers arises:

Rehabilitation Services – includes these services

• Community Psychiatric Support and Treatment (child, adult, and EBPs)
• Psychosocial Rehabilitation (individual, child group, and adult group)
• Peer Support (individual and group)
• Crisis Intervention (emergent and ongoing, rates varied by professional)

Targeted Case Management

Attendant Care (for other than HCBS SED waiver eligibles)

HCBS-SED Waiver Services – includes

• Parent Support and Training (individual and group)
• Independent Living/Skills Building
• Short Term Respite Care
• Wrap Around Facilitation
• Professional Resource Family Care (Crisis Stabilization)
• Attendant Care

Open to all associating providers:

Outpatient Therapy – includes services by LMHPs such as

• Admission/diagnostic evaluation
• Psychological testing
• Individual, family (including in-home) and group psychotherapy

Outpatient Medical Services – includes services by physician, PA, ARNP, RN such as

• Individual psychotherapy by physician, PA, ARNP, RN
• Office consultation
• Limited medication management

Kan-be-Healthy Services – includes

• Mental health assessment (limited and extended)
• Mental health service plan development by LMHP

Case Conference

7. How are the CMHC’s preparing to help clients who will be affected understand what changes will happen and when to expect the changes to happen?  How will CMHC’s respond to the client who asks, “How will this affect me and the services I get now?”

Response: The Kansas Health Solutions will provide information concerning the provision of mental health services to all Medicaid eligible individuals through a beneficiary handbook.  They will also have ombudsmen, a toll free number and other outreach activities.

8.  What is the plan to provide Peer Support services to the adult population and is this part of the State Medicaid Plan or is it part of something else? 

Response: Peer support is a part of the Medicaid Plan.  This is a rehabilitation service that will be provided by the CMHCs.  In addition one of SRS’s University contractors is developing a peer support training program with the CROs.

9. Who is the associate provider: the CMHC or each qualified staff person employed by the CMHC?

Response: The CMHCs will  be providers signed up by the PAHP, all the licensed staff will have to be credentialed by the PAHP. 

10.  Who provides the services for SED/HCBS waiver?

Response: Please see response to question #6 above for SRS expectations for specific categories of services.

11. Talk about why the case manager must be a different person than the community psychiatric support treatment (CPST).  How will the need for two staff persons be handled in the rural parts of the state?

Response: Per CMS rules, individuals who provide Targeted Case Management Services to a participant may not provide other direct services to that participant.

12.  When will the Associate Provider Agreements be available to private practice clinicians for their consideration?  How closely will the Associate Provider Agreements mirror the CMHC state licensure rules and regulations?

Response: It is expected these will be available by mid April.  The CMHC licensing requirements apply only to the CMHCs.

13. What is the rationale for SRS to monitor the Associate Providers (private practitioners)?

Response: SRS will not “monitor” the private practitioners, but the PAHP will like any other Managed Care Organization conduct quality assurance and utilization management activities.  This information will be provided to SRS as our oversight responsibilities of the PAHP.  Part of SRS’s overall program accountability program will include random review of all activities associated with the contract and service system.

14.  Why is there reference to Qualified Mental Health Practitioner (QMHP) in the documents regarding services? 

Response: The State Psychiatric Hospital screenings by statute must  be completed by a QMHP.  All other references to QMHP allow an LMHP to be designated by the PAHP as necessary.

15. What are the performance indicators of services?

Response: Attachment K to the PAHP contract, found at this site, outlines the performance indicators that will be monitored. 

16. How do you anticipate the PAHP contract (KS Health Solutions) and the PIHP contract (ValueOptions) interfacing and working with one another? 

Response: Both contracts have language in them that they each have to work together to ensure services to the dual diagnosed. Now that both contractors have been selected conversations have started between them and SRS program  staff.

17. Situational Examples:  As of July 1 and beyond:   A current  Medicaid client is receiving rehabilitation services and they want to start receiving their care from a private practitioner in their community.  The private practitioner has already become an Associate Provider.  Can this consumer begin receiving the rehabilitation services from the private provider who is an Associate Provider to the PAHP, Kansas Health Solutions, LLC?

Response: No they will  continue receiving services from the CMHCs

18.  A Medicaid client has been seeing a private provider for therapy for three months.  The clinician sees that the client is progressing in therapy but is in need of support services.  She lets her client know to contact the local CMHC to get services going.  How will the coordination of services occur?

Response: If support services are rehabilitation services the person can either be referred to the local CMHC or to the PAHP.  Coordination of services will have to be through a shared treatment plan.

19.  A Medicaid client has contacted a private provider who is an Associate Provider.  The client wants care from this particular private provider and wants to have nothing to do with the local community mental health center based on previous experience with them.  Does this client have to interact, in any way, with the local CMHC to gain mental health care from the private provider?

Response: They would still have to receive rehabilitation services from a CMHC, but if they didn’t want to use their local CMHC they could select another one.  If they don’t need rehabilitation services they can use any provider in the network, with out interacting with the CMHC.

20. Since the CMHC’s will be determining whether or not they have the capacity to meet the service needs of clients, what is to prevent the center from claiming that they have adequate enough resources and that they do not need associate providers to provide any of the Outpatient Services?  

Response:  Access, and the attendant service capacity needed to ensure access, will be measured by the Performance Indicators and related standards included in the PAHP contract.  The Performance Indicators can be seen at Appendix K of the PAHP contract, which can be viewed at www.medicaidtraining.org, by clicking on “PAHP Contract”.   The Network Access Requirements, applicable to all providers (both CMHCs and independent practitioners) are also included in the Liquidated Damages section of the PAHP contract, at pages 147-148.  Adequate service access is not dependent upon any entity “claiming” anything.

21.  What will be the standard of measurement that the PAHP/Kansas Health Solutions use to confirm what the CMHC claims?

Response:  Again, any entity’s “claims” will not be a relevant factor.  Rather, the outcomes of the PAHP contractor, consistent with the Performance Indicators and related standards in the PAHP contract, will be the governing measurements. 

22. How will PAHP/Kansas Health Solutions intervene when the CMHC says they do not need an associate provider to provider a service, but the needed service for a client is not being delivered?

Response:  SRS has contract with Kansas Health Solutions to serve as the PAHP, and has included in that contract the uniformly applicable service and access standards which will be measured and reported according to the specific terms of the contract.  The PAHP is required to proactively assess the ensure the adequacy of the provider network, and one of the governing principals of the contract, stated at page 17, is that “If access problems are detected, the PAHP must actively recruit, train, and subcontract with additional providers including independent practitioners to meet the needs of members.”  If an access standard (or any other standard) of the contract is not being met, the contractually described corrective action and damages provisions will be utilized.  Ultimately, SRS will make a determination of provider network adequacy, based on evaluation of member needs, consumer grievances, and the access and other system performance indicator findings.  

23. Since the CMHC will screen Medicaid clients to determine medical necessity and then the array of needed services, what is to prevent the CMHC from determining that the client only needs the services that the CMHC can provide?   

Response:  This question seems to presume several personal and system characteristics which the PAHP contract and structure do not presume.  For example, a core value of the public mental health system in Kansas is that consumers will direct their care; the contract requires that consumers have access to information about what services are available and what providers are available, and that they have consistent, strong access to those services as well as choice among qualified providers; the contract allows for any qualified subcontracting provider from whom a consumer seeks service to perform the necessary evaluation and, if medical necessity is indicated, provide the services they are qualified to provide, up to the preauthorization limits; and anticipates that there will be increasingly strong connections across and between service systems to support a variety of consumer needs.  In addition, as in all health care delivered by licensed and certified professionals, there is a measure of professional ethics and licensing competence that guides the behavior of the professionals that will be providing mental health services; and, under the PAHP contract there is a required utilization management – including fraud and abuse – process that will be utilized to help ensure the propriety of all service providers.

24.  Since it has been possible all along for the CMHC’s to contract with a private provider to provide services, including for an individual with Medicaid, but they have chosen not to reach out into the community of private providers, how will this mindset change after July 1? 

Response:  In addition to the response immediately above:  Whatever mindset may exist today or on July 1st, there is a dramatically different infrastructure, supported by a binding contract, governed by specific federal regulatory standards, and reinforced by words and actions of SRS in managing the public mental health system.  SRS expects that the PAHP contractor and all of the subcontracting providers will operate in good faith to fulfill the potential of this infrastructure for the benefit of people needing mental health services.

25. What will be the standard measurement of prompt service delivery?  For example, how long must a client wait for an appointment for services to begin, after the initial screening for medical necessity and determination of needed services? 

Response:  The service access standards are set out in the PAHP contract, as noted above, both in the Performance Indicators requirements and the liquidated damages section.  In summary, these standards are:

Network Access Requirement
      Contractor shall assure that Members access services consistent with the standards relative to the urgency of the Members’ service need. 

      Damages
      One thousand dollars ($1,000) per month shall be assessed, at SRS’s discretion, for each of the 8 standards that are not met at least 95 percent of the time for the preceding month.

26.        When an Associate Provider (private practitioner) is providing Outpatient Services, who owns the client record?  Who is responsible for HIPAA compliance for the general record and specifically the psychotherapy records and notes?

Response:  Generally, service providers must retain responsibility for their service records and for compliance with HIPAA and other patient or consumer record protection standards; and, service providers must be accountable to the service monitors and funders (here, including the PAHP contractor and SRS) by – in part – appropriate access to treatment records.  The specific requirements of the PAHP about record access will be included as part of the provider subcontract.

27.        Who owns the Treatment/Intervention Plan? 

Response:  Generally, the Kansas public mental health system value is that consumers should be effectively supported to be informed about and direct their treatment plan.  Providers are responsible to assist consumers in that informing process and then to operate within the boundaries of their professional ethics, licensing requirements, and contract agreements. 

28.        Please talk more about case management and targeted case management.  What is the difference between case management, targeted case management, and CPST? 

Response:  There is no more “case management” in the Kansas public mental health system.  That phrase had gotten confused in the operational culture of the system, whereby two separate services (CPST and targeted case management) had gotten somewhat blurred in some instances.  Effective 7/1/07, the service definitions for CPST services and targeted case management services  – including the prohibition against a single provider delivering both services to the same consumer – will govern.  Those definitions are available for review at Appendix F to the PAHP contract.

29.        Are advisory committees being formed for the PAHP/Kansas Health Solutions and/or SRS as implementation of the State Medicaid Plan and the new Freedom of Choice Waiver gets underway on July 1?    How can one get involved/appointed to serve on such an advisory committee?  What is the schedule and location of these meetings? 

Response:  Extensive stakeholder involvement was obtained prior to building the PAHP contract and related infrastructure.  Going forward, generally there will be three informing bodies that will assist in the readiness for and then implementation of the Mental Health and Substance Abuse 1915(b)/(c) waiver:

1.            Consistent with the PAHP contract, and to accommodate implementation of the contract, SRS and KHS have jointly developed an operational implementation committee with representatives of both parties.  Decisions of the committee will be informed by stakeholders.  One significant way stakeholders will inform the implementation phase is by the stakeholder meeting KHS is sponsoring on the afternoon of 4/20/07, to review and comment upon several critical implementation documents that will guide both provider and member interactions.  Additional updates about readiness activities will be available at the KHS web site, www.kansashealthsolutions.com, and at www.medicaidtraining.org
2.            SRS will be establishing a statewide quality committee to review PAHP performance issues and advise SRS about those issues.  This committee has not yet been established, and if you are interested in participating you can express that interest to Kathy Mosher, who is the PAHP program contact, at 785.296.7272.
3.            SRS also intends to utilize an Oversight Committee appointed by SRS Secretary and supported by SRS Health Care Policy Administration staff.  That committee:  strategically assesses SRS implementation of PAHP/PIHP programs; meets quarterly; reports to SRS Secretary, Legislature, CMS, and system stakeholders.