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Errata: Supplement to PAI pub # 5188.01 January 2008 |
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“A
Guide to Children’s |
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Please disregard the answers to
questions 23 and 24. |
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In 2006, the California
Department of Mental Health adopted new regulations pertaining to Medi-Cal
Mental Health Managed Care Plans (MHPs).
These new regulations change the procedure you use when you disagree
with an Here is a very brief
summary of the new MHP problem resolution process: Appeals Hearings: If you disagree with a Notice of Action and Aid Paid Pending: You have 90
days from the date you receive notice of a denial, termination or reduction
of services to request an Appeal or Expedited Appeal and you have 90 days
from the date of the Grievance Process: If you have a problem with an MHP that does not
involve denial, reduction, or termination of services (for example- quality
of care complaints) you may file a grievance either orally or in
writing. The county must notify you of
its decision on your grievance within 60 days. For more
information about your rights in the Medi-Cal Mental Health Managed Care
problem resolution process, please contact Protection
and Advocacy, Inc. at (800) 776-5746 |
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A Guide To Children’s |
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Protection & Advocacy, Inc. Publication
No. 5188.01 - Revised October 9, 2002 |
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Protection & Advocacy, Inc. (PAI), is a private, nonprofit organization that protects the legal, civil and service rights of Californians who have developmental, psychiatric or other disabilities. PAI provides a variety of advocacy services – including information and referral, technical assistance, and direct representation. For information or assistance with an immediate problem, call: Toll-Free/TDD: 1-800-776-5746 CENTRAL OFFICE (916) 488-9950 (213) 427-8747 BAY AREA OFFICE 1330 Broadway, PAI receives funding under the Developmentally Disabled Assistance and Bill of Rights Act, the Protection and Advocacy for Mentally Ill Individuals Act, the Protection and Advocacy for Individuals with Disabilities Act, and the Protection and Advocacy for Beneficiaries of Social Security Act. Any opinions, findings, recommendations or conclusions expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations that fund PAI. |
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A GUIDE TO |
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TABLE OF CONTENTSSection Page TABLE OF CONTENTS.......................................................................................... i INTRODUCTION................................................................................................. iv 1. What Are Medi-Cal EPSDT Services?........................................................... 1 2. What Mental Health Services are Covered By EPSDT?................................. 1 3. Who Provides EPSDT Mental Health Services?............................................ 2 4. What Is Medical Necessity?........................................................................... 3 5. Can I Choose My Own Mental Health Provider?........................................... 3 6. What is EPSDT Case Management?.............................................................. 4 7. What Are The Language And Cultural Competence Requirements For
EPSDT Providers?.................................................................................................... 5 8. How Much Can An EPSDT Provider Be Paid?.............................................. 5 9. If There Are No Available EPSDT Providers, How Long Do I Have 10. How Do I Qualify For Mental Health Services From the MHP?..................... 5 THERAPEUTIC BEHAVIOR SERVICES
(TBS)..................................................... 6 11. What are EPSDT Therapeutic Behavioral Services (TBS)?............................ 6 12. What is the Emily Q.
lawsuit?....................................................................... 6 13. How Can TBS Help Children Who Would Otherwise Need Out-Of-Home
Placement?.................................................................................................... 7 14. How Many Hours a Day Can A Young Person Get TBS?.............................. 8 15. What Are Examples of TBS Interventions?................................................... 8 16. Does TBS have to Be “Short-Term”?............................................................ 9 17. Can I Receive TBS In Addition To Other Services?...................................... 9 18. Is TBS Different From Respite or Personal Care/In-Home Support 19. Can A Young Person Get TBS When He Is In School?............................... 10 20. When is TBS Not Available?....................................................................... 10 21. What is the Difference Between TBS and “Wraparound”?........................... 10 22. Can Young People Over Age 21 Qualify for TBS?...................................... 11 APPEALS, GRIEVANCES AND
COMPLAINTS.................................................. 11 23. Can I Do Anything If the MHP Does Not Approve My Request (or My
Child’s Request) for EPSDT Services?.................................................................... 11 24. Can I Get “Aid Paid Pending” A Request For A Hearing If I Started
25. If I Appeal, Can I Have Someone Represent Me?........................................ 13 OTHER WAYS TO GET MENTAL
HEALTH SERVICES FOR CHILDREN AND YOUTH................................................................................................................ 13 26. Do Children Covered by Healthy Families Qualify for EPSDT Mental
Health Services?..................................................................................................... 13 27. Can Children Who Are Not Medi-Cal Eligible Get Mental Health
Services through Special Education?...................................................................................... 14 28. When Can Children Get Mental Health Services from the County
Through AB 3632?.......................................................................................................... 14 29. Can Children And Youth Get a One-To-One Aide and Other Behavior
Intervention Services Through Special Education?..................................... 15 30. Instead of referring a student to a residential program, should
the IEP team consider behavior intervention approaches and a one-to-one aide?............. 16 31. What About Children Who are Eligible for Both Medi-Cal and
Special Education?................................................................................................................... 16 32. How Can Children in Foster Care Get EPSDT Services?............................. 17 33. Can Young People in the Delinquency and Juvenile Justice System
Get Mental Health Services?.......................................................................................... 17 34. Should Families Be Forced to Give Up Custody to Get Mental Health
Services for their Child?................................................................................................. 18 35. What is Children’s System of Care and Wraparound?................................. 18 APPENDIX 1........................................................................................................ 21 MEDI-CAL MENTAL HEALTH PLANS (MHPs) BY COUNTY— APPENDIX 2........................................................................................................ 23 State Department of Mental Health - Specialty Mental
Health APPENDIX 3........................................................................................................ 24 COUNTY TBS CONTACT NAMES AND PROVIDERS – 9/30/01............... 24 |
INTRODUCTIONStudies and research indicate that __ to __% of all children need mental health services. For children in the foster care or delinquency systems, the percentage of children estimated to need these services is ___ to ___%. Several different programs pay for mental health services for children. These programs include: (a) the Medi-Cal program, (b) the Healthy Families program, (c) the special education system, or (d) a parent’s private insurance. This guide covers the mental health services available through Medi-Cal. It also briefly covers the Healthy Families program (question 26) and special education (questions 27 to 31). Many children are eligible for Medi-Cal but do not know it because their parents do not know that they qualify. Some children who do not currently get Medi-Cal may be eligible with a monthly share of cost, or by qualifying under one of many new Medi-Cal expansion programs. You can learn more about how to get Medi-Cal from chapters 2 and 3 of a manual called “Overview of the Medi-Cal System,” written by PAI and the Health Consumer Alliance. You can get a copy of the manual from this website: http://www.healthconsumer.org/Medi-CalOverview.pdf. You can also get more information about how to get Medi-Cal from the following websites: www.medicalhomela.org; www.wclp.org; www.bettzedek.org; www.medi-cal.org or by calling PAI at 1-800-776-5746. For more information about how to get mental health services from Special Education, look at the PAI manual Special Education Rights and Responsibilities, PAI publication number 5040.01. Chapters 6 and 9 cover mental health and behavioral problems. The manual s is available by calling the PAI 1-800-776-5746, or from our web-site, www.pai-ca.org/Pubs/. |
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A GUIDE TO Protection & Advocacy, Inc. June 4, 2001, rev. October 30, 2001
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1. What Are Medi-Cal EPSDT Services?All children and youth on Medi-Cal up to age 21 are automatically covered by a special program known as EPSDT. EPSDT stands for “Early and Periodic Screening, Diagnosis, and Treatment.”[1] Under EPSDT, children have a right to all medically necessary services, even if Medi-Cal would not normally cover them for adults. EPSDT services correct or improve medical problems that your doctor or other health care provider finds. EPSDT services may also make a medical problem more tolerable, even if the health problem will not go away entirely. You must be under age 21 and have full scope Medi-Cal to get these services.[2] For physical health care needs, EPSDT covers home nursing and attendant care for up to 24 hours per day for children who would otherwise be in hospitals or nursing homes, special augmentative communication devices, physical and occupational therapy, extra dental services, special durable medical equipment and any other service which is medically necessary and which could be covered by the federal Medicaid program. 2. What Mental Health Services are Covered By EPSDT?EPSDT mental health services are Medi-Cal services that correct or improve mental health problems. These problems may be sadness, depression, nervousness, behavior problems or anger that make life difficult. Some of the EPSDT services you can get from your county mental health department are: · Individual therapy · Group therapy · Family therapy · Crisis counseling · Case management · Special day programs · Medication for your mental health · EPSDT mental health services to treat alcohol and drug problems you may have that affect your mental health. · Therapeutic Behavioral Services (TBS) EPSDT will cover counseling and therapy as often as once or twice per week or more if you and your provider think you need it. You may be able to get these services in your home or in the community. Members of your family can also get counseling and therapy if these services are needed to help you. 3. Who Provides EPSDT Mental Health Services?In 4. What Is Medical Necessity?Medical necessity is the standard used to determine whether any mental health service (whether voluntary or involuntary) is reimbursed under the Medi-Cal program. The standard under EPSDT is whether the services are needed "to correct or ameliorate . . . physical and mental illnesses and conditions . . . , whether or not such services are covered under the State [Medicaid] plan." 42 U.S.C. §1396d(r)(5). Another standard for deciding whether a particular service is medically necessary for you, is whether the service will help with the “maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level.”[5] Medically necessary rehabilitation services should also provide “assistance in improving, maintaining or restoring . . . functional skills, daily living skills, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and support resources and/or medication education.”[6] 5. Can I Choose My Own Mental Health Provider?Yes. The County
Mental Health Plan must allow you to choose between at least two providers in
their network.[7] You can also contact mental health
providers directly by asking for a copy of the county’s list of the mental
health providers in their network, including the providers for children and
youth. The MHP is required to give you
a copy of this list whenever you request it.
You can call the Access line to request the list. If the MHP refuses to give you the list,
you should complain to the state Mental Health Ombudsman at 1-800-896-4042,
or PAI at 1-800-776-5746. If you want
to see a particular provider who does not have a contract with the 6. What is EPSDT Case Management?Case management can be a helpful EPSDT service.[9] For children and their families, the MHP can provide a case manager to help in (a) identifying providers and scheduling appointments, (b) applying for social security or other benefits, (c) getting assessments, completing paperwork and other documentation, (d) finding appropriate school programs and getting services from the school, and (e) generally “advocating for the minor.” [10] For transition age youth who are age 18 and older, mental health case management can also help (a) finding housing and a job, (b) locating vocational programs, (c) developing social support systems, and (d) identifying self-help groups and crisis support. In providing mental health case management, the MHP must identify and focus on children under age 18 who are labeled as “seriously emotionally disturbed” (SED) and who meet any one of these factors: they are Juvenile Court wards or dependents, in a residential placement through special education, an inpatient in a psychiatric hospital or other treatment facility, or who are receiving intensive outpatient services and are at risk of psychiatric hospitalization or out-of-home placement.[11] Young people over age 18 have a similar set of “target criteria: including being an inpatient or at risk of being hospitalized.[12] 7. What Are The Language And Cultural Competence Requirements For EPSDT Providers?Like all Medi-Cal services, mental health services must be provided in a culturally competent manner in your primary language, including sign language.[13] 8. How Much Can An EPSDT Provider Be Paid?An individual provider can expect to be paid market rates as determined by the county. Rates cannot exceed the maximum rate. The current maximum rate for Medi-Cal Mental Health Services, including Rehabilitation Services, is about $120.00 an hour.[14] 9. If There Are No Available EPSDT Providers, How Long Do I Have To Wait For Services?You can be made to wait only for a “reasonable” time, consistent with medical necessity. Federal law requires that all Medi-Cal services be provided with “reasonable promptness.”[15] An MHP may have a waiting list, but it cannot result in an unreasonable delay in providing you with medically necessary services. The federal law regarding EPSDT is even stronger. It is no excuse that existing services are not appropriate or the programs will not agree to serve the child; the state or the MHP must provide needed services, even if these must be individually developed for the particular child. 10. How Do I Qualify For Mental Health Services From the MHP?Contact your THERAPEUTIC BEHAVIOR SERVICES (TBS)11. What are EPSDT Therapeutic Behavioral Services (TBS)?Therapeutic Behavioral Services (TBS) are a new EPSDT mental health service. TBS involves having a trained, experienced staff person available on a one-on-one basis to work with a child with severe emotional or mental disabilities in his or her home and community. TBS is a short-term service intended to prevent a young person from having to go into a more restrictive placement, or to support the transition of a young person from an institutional placement back to the child’s home or community. TBS helps children and young people who: · Have severe emotional problems or difficult behaviors · Live in a mental health placement or are at risk of placement, or · Have been hospitalized recently for mental health problems. TBS is provided based on a written treatment plan which lists: · “target behaviors or symptoms” that put the young person at risk (such as tantrums, property destruction, assaultive behavior at school), · specific interventions to resolve those behaviors, · outcome measures to show that the target behaviors have been reduced. The TBS treatment plan will be reviewed monthly and adjusted to identify new target behaviors, interventions or outcome measures. The plan will also include a transition plan to decrease or stop TBS over time, since it is a short-term service. Each 12. What is the Emily Q. lawsuit?Young people are members of the Emily Q. class action if they are under 21, receive full-scope (not restricted) Medi-Cal and: (a) are placed in a Rate Classification Level ("RCL") facility level 12 or above and/or a locked treatment facility for the treatment of mental health needs; (b) are being considered for placement in these facilities; or (c) have undergone at least one emergency psychiatric hospitalization related to their current presenting disability within the preceding 24 months. Not all class members will qualify to actually receive TBS. The most important additional requirement is that the young person must be at risk of being placed in a higher level of residential care if he does not receive TBS or that he must need TBS to transition to a less restrictive setting. The young person must be receiving at least one other type of specialty mental health service, such as therapy or medication management.[17] 13. How Can TBS Help Children Who Would Otherwise Need Out-Of-Home Placement?TBS can help prevent the need for out-of-home placement
when a child’s behaviors are too difficult for her parents or caregivers to
deal with alone. A TBS aide or “coach”
can help by supporting the child in her family home, group home, foster home
or in some other types of residential facility. The Federal Court ordered
that the TBS can also help a young person who is in out-of-home placement come home, or move to a lower level of placement than would have been possible otherwise. For example, a young person may start with a TBS aide as support during home visits for evenings or weekends, and then continue with a TBS aide for more hours every day when he is ready to come home full-time. 14. How Many Hours a Day Can A Young Person Get TBS?A young person can get TBS for as many hours per day as she, her mental health provider and MHP decide she needs this support. There are no arbitrary limits. Some young people get TBS for 16 hours per day, others for 6 hours per day, others for only a few hours in the morning or after school.[18] Young people can also get TBS seven days per week, only on weekends, or in other combinations based on their treatment plans. 15. What Are Examples of TBS Interventions?The TBS staff person “provides behavior modeling, structure and support, and immediate, frequent, one-to-one behavior interventions which assist the child/youth in engaging in appropriate activities, minimizing impulsivity, and increase social and community competencies by building or reinstating those daily living skills that will assist the child to live successfully in the community. The TBS provider also serves as a positive role model ...”[19] The following are examples of what a TBS coach might do: Behavior/Impulse Control Interventions: · Reminding child to take a time out when he become distressed · Helping child develop self-calming skills · Offering praise and supporting self-recognition when child controls himself Communication Skills Interventions: · Helping child identify feelings she wants to communicate with parent · Role-play communication skills for child and for child and parent Enhanced Community Functioning: · Take child on trip to shopping mall, model social interactions with others · Take child on youth group trip, discuss conflict resolution issues afterwards · Increase child’s motivation to use good personal hygiene though praise and recognition, discussion of aspects of dress, hygiene 16. Does TBS have to Be “Short-Term”?TBS is defined as a “short-term intervention” which means that it cannot continue forever. However, the state has never defined “short-term.” Generally TBS services are approved for periods of 3 to 6 months, with a plan to eventually terminate the service entirely. If a young person is making some progress in meeting his or her goals over each evaluation period, we believe that TBS could continue for a year or more and still meet the requirement of being “short-term.” If the MHP decides to terminate TBS because the young person is not making enough progress, be sure to request a state fair hearing immediately. In some cases, TBS can then continue during the appeal.[20] 17. Can I Receive TBS In Addition To Other Services?Yes. First, TBS can
only be provided if the young person is getting at least one other service
from the MHP, such as therapy or case management. TBS can also be provided in combination
with other services as long as there is no duplication. For example, a young person both
participate in a day treatment program and get TBS at the same time,
depending on individual need. A young
person who has a dual diagnosis of mental health and developmental disability
can receive services from both the 18. Is TBS Different From Respite or Personal Care/In-Home Support Services?Yes. TBS and other mental health Rehabilitation services assist a beneficiary in improving, maintaining or restoring skills, and are offered through a mental health treatment plan that with specific treatment goals. Respite care or attendant care services such as Personal Care Services Program/In-Home Supportive Services (PCSP/IHSS) provide assistance to the Medi-Cal beneficiary or to her family but are not necessarily designed to improve, maintain or restore skills. 19. Can A Young Person Get TBS When He Is In School?TBS can be provided in a school setting if all the criteria for TBS are met. One-on-one behavior services can also be provided through special education, but these have different goals. TBS services are short-term interventions aimed at changing behaviors which put the child at risk of out-of home placement or prevent transition to a lower level of placement; they are provided based on a mental health assessment. Educational aide services may be long-term, are intended to help a child achieve his education goals or to maintain the child in an educational placement and are provided based on the child’s IEP.[22] 20. When is TBS Not Available?TBS is not available when it is needed: Solely for the convenience of the caregiver (but the TBS aide can work on assisting the caregiver with skills and strategies) Solely to provide supervision or assure compliance with probation Solely to ensure the child/youth’s physical safety or the safety of others (i.e., suicide watch) · Solely to address conditions which are not part of the child’s mental health condition · When the child can sustain non-impulsive self-directed behavior, handle himself appropriately in social situations with peers and are able to appropriately handle transitions through the day. · When the child will never be able to sustain non-impulsive behavior and engage in appropriate community activities without full-time supervision · When the young person is an inpatient resident of a hospital, IMD (institution for Mental Disease), psychiatric health facility or crisis residential facility. 21. What is the Difference Between TBS and “Wraparound”?Wraparound programs are available on a pilot basis in some counties and some geographic areas of some counties. Wraparound is provided to children who are involved with child welfare service or probation and at risk of out-of-home placement; it is not limited to children on Medi-Cal. TBS is a Medi-Cal entitlement available throughout the state, not a pilot. TBS may be effectively provided through a wraparound program, but is not limited to wraparound.[23] 22. Can Young People Over Age 21 Qualify for TBS?Normally, EPSDT services such as TBS are only available to young people who are under age 21. However, the Federal Court in the Emily Q. case ordered that young people could get TBS even if they are over 21 if they can show that they would have qualified at some time from May 1997 to the May, 2001, but the MHP did not offer them TBS. This is called “compensatory TBS.” The young person’s TBS provider needs to submit a request to the MHP with an explanation of why TBS would have helped the young person in the past and why the MHP did not provide it. In addition, adults over 21 can get similar services, called One-to-One Mental Health Rehabilitation services, which can be also provided at home, in a residential facility or in the community.[24] These can be long-term and are not limited to the short-term as TBS is. For more about One-to-One Mental Health Rehabilitation Services, look at PAI Publication No. 5182.01. APPEALS, GRIEVANCES AND COMPLAINTS23. Can I Do Anything If the MHP Does Not Approve My Request (or My Child’s Request) for EPSDT Services?Yes. There are several things you can do if (a) the county MHP denies the EPSDT services requested by your doctor or provider, (b) you think you need mental health services and your provider, or the county MHP does not agree, or (c) you have waited an unreasonable amount of time for a response from the MHP to your request for EPSDT services. If you were denied, you can ask for a second opinion.[25] You can also appeal if your request for services was denied or not approved in a reasonable time. There are three ways to do this: · Complaint process (by speaking to the MHP grievance coordinator). · Grievance process (by filling out a written grievance form) · State fair hearing (by writing, calling or faxing the state hearing office) You can pursue all three procedures one at a time or at the
same time.[26] No
matter which route you choose, if you want a state fair hearing, you must ask
for the hearing 90 days after the date you receive written notice that the
service has been denied.[27] If you did not get a written denial, you
can still appeal; there is no 90-day time limit but you still should not wait
too long. To file a grievance or complaint, call the county mental health department’s toll free number to talk to a grievance coordinator for information and help. You may also call the county patient’s rights advocate, or the State Mental Health Ombudsman Office. You can ask for a State hearing at the same time. Call 1-800-952-5253, send a fax to
916-229-4110, or write to the Department of Social Services/State Hearings
Division, 24. Can I Get “Aid Paid Pending” A Request For A Hearing If I Started Getting EPSDT Services And These Were Terminated, Reduced Or Suspended By The MHP?Yes. Once you are receiving a Medi-Cal mental health service, you have a right to written notice at least 10 days prior to the termination, reduction or suspension of that service. The notice must explain what the county is doing and why, and how you can appeal the decision. You have a right to continue to receive the service at least until the state fair hearing, if you request the state fair hearing before the date of the intended action. This is called “aid paid pending” the hearing.[28] Often the MHP will approve EPSDT services for a limited period, such as 3 or 6 months. (This will almost always be true for TBS benefits.) There are special rules about getting continued benefits pending a hearing in this situation. If your EPSDT provider requests re-authorization and the MHP denies this request, you must appeal within 10 days of getting the denial notice or before the end of the old authorization period. |