1	Accessing Healthcare Coverage for Mental Health Services for Your Child Presented by: The Association for Children’s Mental Health
2	Association for Children’s Mental Health Mission Our mission is to promote the development of a system of care for the families of children with emotional, behavioral, or mental health disorders through community education and awareness, family support and involvement and the persistent pursuit of advocacy to improve the quality of life for Michigan’s families through: Community Education/Awareness Family Support Family Involvement Systems Change
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4	Frequently Asked Questions Who can I go to for help? Three W’s Who, What & Where? What is Community Mental Health? Accessing Services from Community Mental Health SED Criteria Denials How Will I Pay for Mental Health Services? Medicaid & General Fund Considerations for Coverage Determinations Service Array MI-CHILD Private Health Insurance
5	Who can I go to for Help? Where do I start? Start with your child’s pediatrician For an initial determination For a referral for a mental health assessment For a referral to a mental health provider No pediatrician? Ask your child’s school for an evaluation Contact your local Community Mental Health Service Program (CMHSP)
6	Three W’s: Who, What and Where Who will provide the services? Services may be provided by one or a combination of mental health care professionals What services will be provided? Services will be dependent upon the individual needs of your child and their family Where will services be provided? Services will be accessed and provided in different ways dependent upon your type of insurance (public and/or private) and the severity of your child’s condition
7	What is Community Mental Health? (CMHSP) The Community Mental Health Services Program (CMHSP) is the manager for various funding sources, service arrangements, and benefits that have different priorities, eligibility determinates, service use qualifications and legal constraints The Mental Health Code* states/defines: The purpose of a CMHSP is to “…provide a comprehensive array of mental health services appropriate to conditions of individuals who are located within its geographic service area, regardless of an individual’s ability to pay.” Services provided by a CMHSP shall be directed to individuals who have a serious mental illness, serious emotional disturbance, or developmental disability Priority shall be given to the provision of services to individuals with the most severe forms of serious mental illness, serious emotional disturbance, or developmental disability Priority shall be given to the provision of services to individuals with the most severe forms of serious mental illness, serious emotional disturbance, or developmental disability in urgent or emergency situations Priority is defined as “…a preference for and dedication of a major proportion of resources to a specified populations or services. Priority does not mean serving or funding the specified populations or services to the exclusion of other populations or services.” *P.A. 254 of the Public Acts of 1974, as amended
8	What is Community Mental Health? Accessing Services from CMHSP/Eligibility Contact your local CMHSP Customer Services for: General information on CMHSP services Contact information for the CMHSP ACCESS for a coverage determination The CMHSP will do a coverage determination for eligibility for publicly funded specialty mental health services and supports and if your child is determined eligible then the service array for specialty mental health services and supports will be based upon medical necessity, allocation of resource, and the funding source If your child does not have Medicaid Specialty mental health services and supports will be based upon the CMHSP dedication of specific proportion of its state allocation specified for priority populations (while assuring that a specific priority population or service to the exclusion of other priority populations or other mandated services If your child does have Medicaid and is determined to be eligible then the specialty mental health services and supports Will be based upon medical necessity From a service array made up of mandatory and optional services Will be sufficient in amount scope and duration to meet the identified need
9	What is Community Mental Health? Coverage Determinations/Eligibility Serious Emotional Disturbance (SED) Eligibility criteria for a Serious Emotional Disturbance (SED): A diagnosable mental, behavioral, or emotional disorder affecting a minor that: Exists or has existed during the past year for a period of time sufficient to meet the diagnostic criteria specified in the most recent diagnostic statistical manual of mental disorders (DSM) The condition must result in a functional impairment that substantially interferes with or limits the minors role or functioning in: family, school, community activities Substance abuse disorder, a developmental disorder, and “V” codes in the DSM are included is they occur in conjunction with another diagnosable serious emotional disturbance. Michigan Mental Health Code *If your child is determined to be eligible for services but is not on Medicaid your ability to pay (ATP) will be determined by the CMHSP
10	What is Community Mental Health? Denials Medicaid, Uninsured/Underinsured, MI-CHILD If following a coverage determination by the CMHSP and your child is determined not eligible you can appeal the decision made by the CMHSP Appeal options differ dependent upon the funding source for services The following are the options available to appeal a denial of service from a CMHSP Medicaid Eligible Second Opinion (intake & hospitalization) Medicaid Fair Hearing (may be concurrent with the Local Appeal) Local Appeal General Fund (as the payment source) Second Opinion (intake & hospitalization) Local Appeal MDCH Review Medicaid (following a Local Appeal with the CMHSP) Whatever insurance coverage you do or don’t have remember: Individuals shall not be denied a service because of an inability unable to pay.
11	How Will I Pay for Mental Health Services? Factors There is no simple answer It depends on your particular situation and many factors: Child and family needs Financial situation Health insurance coverage Income level Coverage determination (eligibility) Community resources Adoption subsidies Boundary issues (i.e. School, Court, and DHS)
12	How Will I Pay for Mental Health Services? Scenarios Medicaid Uninsured/underinsured MI-CHILD insurance Private Health Insurance
13	How Will I Pay for Mental Health Services? Medicaid Eligible General Information Contact the Department of Human Services (DHS) Further information on Medicaid eligibility To apply for Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT) States participating in the Medicaid program must provide a health screen to all children under 21 years of age Including mental health screenings Children and youth are entitled to any service covered by Medicaid to correct or make better any problems identified through the screen Contact your local Community Mental Health Service Program (CMHSP) for a coverage determination. They will: Determine if your child meets the severity criteria Authorize needed services and supports Assist with obtaining needed services and supports If your child does not meet the severity criteria your child may be referred to a Medicaid Health Plan (MHP) The MHP is a comprehensive health care plan that may provide up to twenty mental health outpatient visits per year.
14	How Will I Pay for Mental Health Services? CMHSP Considerations for Making Coverage Determinations Medicaid and General Fund Mental Health Code Requirements to consider when identifying and providing mental health services and supports: Shall promote the best interest of the child Designed to increase independence, Improve quality of life Support community integration and inclusion Designed to strengthen and preserve the family unit Cannot fund a particular priority population of service to the exclusion of other priority populations or mandated services Additional considerations for specialty mental health services and supports funded by Medicaid: Must be sufficient in amount, scope, and duration to meet the need of child Must be based upon medical necessity The payer of last resort
15	How Will I Pay for Mental Health Services? Considerations for Making Coverage Determinations Medical Necessity-Medicaid MEDICAL NECESSITY CRITERIA FOR MEDICAID MENTAL HEALTH, DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE SUPPORTS AND SERVICES Medical Necessity Criteria Mental health, developmental disabilities, and substance abuse services and supports, services, and treatment. Necessary for screening and assessing the presence of a mental illness, developmental disability or substance use disorder; and/or Required to identify and evaluate a mental illness, developmental disability or substance use disorder; and/or Intended to treat, ameliorate, diminish or stabilize the symptoms of mental illness, developmental disability or substance use disorder; and/or Expected to arrest or delay the progression of a mental illness, developmental disability, or substance use disorder; and/or Designed to assist the individual to attain or maintain a sufficient inclusion and participation, independence, recovery, or productivity
16	How Will I Pay for Mental Health Services? Medicaid & General Fund Service Array Medicaid Defined in the Medicaid Provider Manual Array is dependent upon Waiver Type Freedom of Choice Waiver/1915 (b) Home and Community Based Care Waiver/1915 (c) SED Children’s Waiver See Handout General Fund Minimum services are identified in the Mental Health Code Additional service provisions are based locally upon priority, need and resources See Handout
17	How Will I Pay for Mental Health Services? MI-CHILD What is it? MI-CHILD is a state financed program Provides low-cost health insurance for children under age 18 without health coverage Community Mental Health is the only provider of services for mental health regardless of the severity or diagnosis of the child. To get an application call: 1-888-988-6300
18	How Will I Pay for Mental Health Services? Private Health Insurance Basics and Managed Care
19	How Will I Pay for Mental Health Services? Private Health Insurance Limitations, Exclusions & Terms
20	Private Health Insurance Know Your Plan Special Private Policy Sections Definition Section: Look for definitions in your policy to terms that may fit your family’s circumstances Pay special attention to terms that are often used to deny services: Medically necessary Chronic Custodial Care Benefits Section: Identify section that applies to your family and read the sections about specific benefits for: Limitations Exclusions Case Management benefit For specifics Option to negotiate for additional benefits outside of regular benefits identified in the regular benefit package.
21	Private Health Insurance Know Your Plan Deductibles, Co-Payments & Service Limits
22	Resources For more information about accessing health care coverage for mental health services: Local ACMH office ACMH main office 1-888-226-4543 Your local Community Mental Health Service Program The Michigan Department of Community Health