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Hallelujah!!!!!!!-- SB 18-250 -- Jail Based behavioral Health Services, Screening, Coordination with transitional care coordination

4/23/2018

SB18-250 is subject to available appropriations.

With regard to coordination with the Mental Health Centers -- that certainly implicates Medicaid.

Medicaid is an entitlement & there are now how stricter rules on Network Adequacy. We are very interested in finding out how this might be coordinated with Medicaid to ensure Parity & Network Adequacy.

SB18-250 Bill Summary

The bill continues to allow the correctional treatment cash fund to be used to provide treatment for persons with mental and behavioral health disorders who are being served through the jail-based behavioral health services program (program).

The program is housed in the office of behavioral health.

The purpose of the program is to provide adequate staff to complete competency screenings, prescribe psychiatric medications as necessary, and provide mental health counseling and transitional care coordination; train jail staff on behavioral health disorders and best practices in working with individuals with mental health, substance use, and co-occurring disorders; and fund administrative costs to jails participating in the program.

Jails that are participating in the program shall, at a minimum:

Screen individuals who are being booked into the facility for various behavioral health issues;
Provide adequate and appropriate access to health care and medications;
Coordinate services with community mental health providers prior to the release of an inmate to ensure continuity of care following his or her release from the jail facility; and
Track performance outcome measures for individuals affected by the program.
(Note: This summary applies to this bill as introduced.)

SB18-250
Jail-based Behavioral Health Services
Concerning the provision of jail-based behavioral health services.

Introduced April 17, 2018

With Medicaid Network Adequacy, CMS is Potentially bringing disability Enforcement to the Wild, wild States

4/21/2018

The Federal Medicaid Network Adequancy Standards are pretty impressive, and they are meant to deal with long term problems in Medicaid Network Adequacy in each of the States.

If States really do this, it could be a game-changer. If they don't, there should be possibility of CMS Administrative Enforcement.

What we really like is that the Feds put the minimum Medicaid Network Adequacy into the Code of Federal Regulations.

But beyond that it really provides a roadmap for States.

It is pretty clear that State Officials across the country need somebody on high saying they have to do this and having mechanisms for relative ease of enforcement.

I think State Officials need the "out" of mandatoriness and blaming it on the Feds, CMS, whoever.

Further, we've often talked in terms of a lack of Courage as being responsible for Colorado's failure and the National Failure to comply fully with Olmstead.

In reality, it has probably been a lack of Power that has led to the widespread compliance failures.

It seems to us, with the federal regulations governing Medicaid Network Adequacy -- CMS is stepping into the wild, wild Country of disability rights unenforcement and providing the potential for pragmatic and easily accessible enforcement -- @ least in healthcare.








  .

42 CFR 438.68(c) Development of Medicaid Network Adequacy Standards

(c) Development of network adequacy standards.

(1) States developing network adequacy standards consistent with paragraph (b)(1) of this section must consider, at a minimum, the following elements:

(i) The anticipated Medicaid enrollment.

(ii) The expected utilization of services.

iii) The characteristics and health care needs of specific Medicaid populations covered in the MCO, PIHP, and PAHP contract.

(iv) The numbers and types (in terms of training, experience, and specialization) of network providers required to furnish the contracted Medicaid services.

(v) The numbers of network providers who are not accepting new Medicaid patients.

(vi) The geographic location of network providers and Medicaid enrollees, considering distance, travel time, the means of transportation ordinarily used by Medicaid enrollees.

(vii) The ability of network providers to communicate with limited English proficient enrollees in their preferred language.

(viii) The ability of network providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment for Medicaid enrollees with physical or mental disabilities.

(ix) The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions.

OrCHID after Almost 5 years -- Where Are We & WHere are We Going

4/19/2018

So a BIG part of Orchid has been information sharing, recognizing that access to official documents can be all one needs to win the day with a provider or official.
It's probably no surprise that my top strength under "StrengthsFinder" is INPUT. I take in a lot of information -- and information is power.
But as we have learned it is NOT always enough in a polite world of MIGHT MAKES RIGHT.
We also learned our limits -- it probably is possible for one person with no support staff to mount a Class Action Lawsuit against the State -- but that person isn't me.
So what are we planning for the next year of so:

We've got a lot of people coming to the Orchid website -- so we are going to keep providing a lot of information;
We're going to focus on submitting requests for information to State Agencies in Collaboration with individuals & Advocates.
Administrative Enforcement through both Federal & State Agencies.
Two Annual CLEs [Continuing Legal Education Seminars] available to attorneys and the Community:
- CO Compliance & Challenges with Medicaid Network Adequacy, Mental Health Parity & Addiction Equity Act under Medicaid, & Olmstead [Title II of the Americans with Disabilities Act]
- New Science & Legal Implications for Services, etc. Likely a panel discussion on when if ever Medicaid should seek a waiver on an experimental treatment. Will also likely include latest diet information for good mental health and its legal implications.
Collaborate & Partner with the larger CO Legal Community to address unresolved systemic issues through other means, including litigation.

Rough Draft on Our Thoughts on Network Adequacy for CO Medicaid

4/18/2018

To the right we've made some notes regarding things we would think the Colorado Department of Health Care Policy & Financing needs to include in their network adequacy analysis.

Under the regulations a state can consider other provider types if it promotes the objectives of the Medicaid program. We have listed several additional types some of which may be available in part.

We're going to circulate this draft to other individuals and advocates in the mental health & disability community.

Feel free to e-mail me @ [email protected] with any thoughts you might have. I anticipate communicating some of our concerns regarding Network Adequacy to the State on Tues. April 17, 2018.

We may put this in the form of questions -- so that the State could answer those questions and then post them as Frequently Asked Questions.

42 CFR § 438.68 Network adequacy
standards.

(a) General rule. A State that contracts with an MCO, PIHP or PAHP to deliver Medicaid services must develop and enforce network adequacy standards consistent with this section.

(b) Provider-specific network adequacy standards.

(1) At a minimum, a State must develop time and distance standards for the following provider types, if covered under the contract:

(i) Primary care, adult and pediatric.

(ii) OB/GYN.

(iii) Behavioral health (mental health and substance use disorder), adult and pediatric.

Assertive Community Treatment providers

(iv) Specialist, adult and pediatric.

Immunologists
Gastro-entrologists
Psycho-pharmacologists
Dieticians
Genetic testing where appropriate for medications

(v) Hospital.

Sufficient beds for Psychiatric hospitalization
Sufficient beds for Substance Use Disorder inpatient treatment
Sufficient beds for Psychiatric hospitalization that accommodates people with physical disabilities
Sufficient beds for Substance Use Disorder inpatient treatment.
Acute treatment units should be included in network adequacy.

(vi) Pharmacy.
Should be based on the individual needs of the person.

(vii) Pediatric dental.

(viii) Additional provider types when it promotes the objectives of the Medicaid program, as determined by CMS, for the provider type to be subject to time and distance access standards.

Finnish Open Dialogue approach, piloted in Massachusetts & Georgia
Soteria approach to Mental Health Care
Hearing Voices Network
Art therapy
Culinary (Cooking) Art therapy
Music therapy
Lyric/Rap Writing therapy
Writing therapy
Equine therapy
Dog Training therapy
Gardening therapy

(2) LTSS. States with MCO, PIHP or PAHP contracts which cover LTSS must develop:

(i) Time and distance standards for LTSS provider types in which an enrollee must travel to the provider to receive services; and

(ii) Network adequacy standards other than time and distance standards for LTSS provider types that travel to the enrollee to deliver services.

(3) Scope of network adequacy standards. Network standards established in accordance with paragraphs (b)(1) and (2) of this section must include all geographic areas covered by the managed care program or, if applicable, the contract between the State and the MCO, PIHP or PAHP. States are permitted to have varying standards for the same provider type based on geographic areas.

(c) Development of network adequacy standards.

(1) States developing network adequacy standards consistent with paragraph (b)(1) of this section must consider, at a minimum, the following elements:

(i) The anticipated Medicaid enrollment.

From CO Jails & Prisons
Who are homeless

(ii) The expected utilization of services.

Behavioral Health by service
Brain Injury by service
Developmental Disability by Service
Substance Use Disorder by Service
etc.

(iii) The characteristics and health care needs of specific Medicaid populations covered in the MCO, PIHP, and PAHP contract.

From CO Jails & Prisons
Homeless

(iv) The numbers and types (in terms of training, experience, and specialization) of network providers required to furnish the contracted Medicaid services.

(v) The numbers of network providers who are not accepting new Medicaid patients.

(vi) The geographic location of network providers and Medicaid enrollees, considering distance, travel time, the means of transportation ordinarily used by Medicaid enrollees.

(vii) The ability of network providers to communicate with limited English proficient enrollees in their preferred language.

(viii) The ability of network providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment for Medicaid enrollees with physical or mental disabilities.

(ix) The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions.

(2) States developing standards consistent with paragraph (b)(2) of this section must consider the following:

(i) All elements in paragraphs (c)(1)(i) through (ix) of this section.

(ii) Elements that would support an enrollee's choice of provider.

(iii) Strategies that would ensure the health and welfare of the enrollee and support community integration of the enrollee.

(iv) Other considerations that are in the best interest of the enrollees that need LTSS.

(d) Exceptions process.

(1) To the extent the State permits an exception to any of the provider-specific network standards developed under this section, the standard by which the exception will be evaluated and approved must be:

(i) Specified in the MCO, PIHP or PAHP contract.

(ii) Based, at a minimum, on the number of providers in that specialty practicing in the MCO, PIHP, or PAHP service area.

(2) States that grant an exception in accordance with paragraph (d)(1) of this section to a MCO, PIHP or PAHP must monitor enrollee access to that provider type on an ongoing basis and include the findings to CMS in the managed care program assessment report required under §438.66.

(e) Publication of network adequacy standards. States must publish the standards developed in accordance with paragraphs (b)(1) and (2) of this section on the Web site required by §438.10.

Upon request, network adequacy standards must also be made available at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services.

https://www.ecfr.gov/cgi-bin/text-idx?SID=ee060aef565a027e0646f68a1927b9d6&mc=true&node=se42.4.438_168&rgn=div8

CMS, Network Adequacy, & the Possibility of More Consistent Enforcement for People with Disabilities

4/17/2018

CMS has really raised it's game with the new focus on "Network Adequacy"

Within the last 4 years there have been 3 major federal government reports criticizing network adequacy in Medicaid and Medicare. [See the Orchid menu under Hot Topics & Network Adequacy.]

Of course, if states don't have Network Adequacy -- there is a pretty good chance that States are NOT complying with:

Olmstead & the Americans with Disabilities Act (ADA), or
the Mental Health Parity & Addiction Equity Act (MHPAEA)

Of course, Olmstead covers more than just healthcare -- but Medicaid Network Adequacy Standards sound in some ways tougher than an Olmstead Plan with:

Measurable Goals
Reasonable Time Frames &
Funding to Support the Plan

Network Adequacy requirements appear to require adequate Medicaid Networks---NOW.

Of course, States had 18 years to comply with Olmstead and they didn't do it. Colorado didn't do it.

We will be analyzing the Department of Health Care Policy & Financing's efforts to comply with CMS' Medicaid Network Adequacy requirements.

Availability addresses whether provider networks are sufficient to meet the needs of enrollees. Availability is a function of the number of providers, their willingness to participate in the program, and their ability to offer timely appointments. Provider participation, in turn, is influenced by reimbursement rates, timeliness of payment, and administrative burden.
Accessibility involves the proximity of providers to enrollees, based on geographic time and distance. For long-term services and supports (LTSS) provided in a home or community setting, accessibility can be expressed as the time and distance for caregivers to travel to enrollees’ residences. At the point of care, accessibility is determined by physical access, such as ramps, and providers’ ability to communicate in non-English languages or sign language.
Accommodation is the extent to which a provider’s operating hours, appointment policies, language and cultural competencies, and approach to communications meet enrollees’ constraints and preferences.
Acceptability captures whether enrollees and providers are comfortable with and relate well to one another, and the extent to which managed care plans and providers respect and respond to enrollees’ concerns and preferences.
Affordability encompasses the costs that enrollees incur relative to their ability to pay, subject to Medicaid and CHIP rules limiting enrollee cost-sharing amounts.
Realized access addresses managed care enrollees’ actual use of the services covered under the contract. For monitoring purposes, it is most important to measure the use of clinically recommended care, such as preventive screenings and immunizations, as well as services that could be markers of potential access problems, such as hospital admissions for chronic conditions that can be avoided through regular outpatient care.

Access-related provisions in the final rule. The final rule focuses on four of these six dimensions of access: availability, accessibility, accommodation, and realized access.

Table I.1 is a list of the major access-related requirements in the final rule in the order of citation in 42 CFR 438 and the toolkit chapters in which they are discussed. Although the final rule does not explicitly address acceptability of services, patient satisfaction measures and grievances and appeals can inform states as to whether managed care plans are meeting enrollees’ needs.

The Medicaid and CHIP managed care final rule also does not address affordability, but other federal regulations (for example, 42 CFR 447.56 and 42 CFR 457.540) require state Medicaid and CHIP agencies to limit premiums and cost-sharing to 5 percent of family income, and track beneficiary out-of-pocket spending against this limit.

42 CFR §438.68 Network adequacy standards.

(a) General rule. A State that contracts with an MCO, PIHP or PAHP to deliver Medicaid services must develop and enforce network adequacy standards consistent with this section.

(b) Provider-specific network adequacy standards. (1) At a minimum, a State must develop time and distance standards for the following provider types, if covered under the contract:

(i) Primary care, adult and pediatric.

(ii) OB/GYN.

(iii) Behavioral health (mental health and substance use disorder), adult and pediatric.

(iv) Specialist, adult and pediatric.

(v) Hospital.

(vi) Pharmacy.

(vii) Pediatric dental.

(viii) Additional provider types when it promotes the objectives of the Medicaid program, as determined by CMS, for the provider type to be subject to time and distance access standards.

(2) LTSS. States with MCO, PIHP or PAHP contracts which cover LTSS must develop:

(i) Time and distance standards for LTSS provider types in which an enrollee must travel to the provider to receive services; and

(ii) Network adequacy standards other than time and distance standards for LTSS provider types that travel to the enrollee to deliver services.

(3) Scope of network adequacy standards. Network standards established in accordance with paragraphs (b)(1) and (2) of this section must include all geographic areas covered by the managed care program or, if applicable, the contract between the State and the MCO, PIHP or PAHP. States are permitted to have varying standards for the same provider type based on geographic areas.

(c) Development of network adequacy standards.

(1) States developing network adequacy standards consistent with paragraph (b)(1) of this section must consider, at a minimum, the following elements:

(i) The anticipated Medicaid enrollment.

(ii) The expected utilization of services.

iii) The characteristics and health care needs of specific Medicaid populations covered in the MCO, PIHP, and PAHP contract.

(iv) The numbers and types (in terms of training, experience, and specialization) of network providers required to furnish the contracted Medicaid services.

(v) The numbers of network providers who are not accepting new Medicaid patients.

(vi) The geographic location of network providers and Medicaid enrollees, considering distance, travel time, the means of transportation ordinarily used by Medicaid enrollees.

(vii) The ability of network providers to communicate with limited English proficient enrollees in their preferred language.

(viii) The ability of network providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment for Medicaid enrollees with physical or mental disabilities.

(ix) The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions.

(2) States developing standards consistent with paragraph (b)(2) of this section must consider the following:

(i) All elements in paragraphs (c)(1)(i) through (ix) of this section.

(ii) Elements that would support an enrollee's choice of provider.

(iii) Strategies that would ensure the health and welfare of the enrollee and support community integration of the enrollee.

(iv) Other considerations that are in the best interest of the enrollees that need LTSS.

(d) Exceptions process.

(1) To the extent the State permits an exception to any of the provider-specific network standards developed under this section, the standard by which the exception will be evaluated and approved must be:

(i) Specified in the MCO, PIHP or PAHP contract.

(ii) Based, at a minimum, on the number of providers in that specialty practicing in the MCO, PIHP, or PAHP service area.

(2) States that grant an exception in accordance with paragraph (d)(1) of this section to a MCO, PIHP or PAHP must monitor enrollee access to that provider type on an ongoing basis and include the findings to CMS in the managed care program assessment report required under §438.66.

(e) Publication of network adequacy standards. States must publish the standards developed in accordance with paragraphs (b)(1) and (2) of this section on the Web site required by §438.10.

Upon request, network adequacy standards must also be made available at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services.

https://www.ecfr.gov/cgi-bin/text-idx?SID=ee060aef565a027e0646f68a1927b9d6&mc=true&node=se42.4.438_168&rgn=div8

Overexcitabilities, Sensitivities & Prone to Mental Health Issues --It is Time for the Mental Health Profession To Wake Up to the Complexities & "Special Needs" of People Who Are "Gifted"

4/16/2018

Giftedness is often a "Special Needs" category -- people have "gifts" but they also have significant challenges and issues.

Further, giftedness is found in every race, ethnicity, and socio-economic background.

If you pair giftedness with child abuse, an abusive society, etc. -- the results can be very difficult. There may be the expectation the gifted person through some type of ability will rise above it --- the reality is the gifted person is probably much more sensitive to the abuse and more likely to suffer mental health effects from it.

Some of the brightest people I've ever known went on to achieve amazing things.

Some of these bright people have been sidetracked by mental health issues and at least two experience great injustice from well meaning people who didn't know what they were seeing:

One of the most brilliant people I know is also one of the kindest guys I know. He made a perfect score on his LSAT [the examination to get into law school] and later spent 7 years homeless in a major US metropolitan city. He subsequently went back to law-- as well as acting and directing.

A Black Colorado Jail House Lawyer who has been homeless since he was 11 years old, on SSI for mental issues -- The System knows he is different but they don't know what to do with him, and often misinterpret him. The unscientific "anti-social personality disorder" is doing such great harm -- maybe somebody @ some point is going to see it.

White super intense, excitable tall guy on the Forensics Unit @ the Colorado Mental Health Institute @ Pueblo. At one point, all kinds of state officials were repeating that this guy had an "anti-social personality disorder diagnosis" even though he didn't meet the criteria. In fact, he had a good and uneventful childhood and had a degree in Computer Science from a major university.

So the point is -- ignorance of gifted asynchrony, overexcitabilities and special needs does A LOT OF HARM. Mental health professionals need to be able to recognize:

gifted over-excitabilities and sensitivities
the wide range of gifted abilities
the wide range of people in every race, ethnicity, class, and social economic background who are gifted
common challenges and issues

Genius & Madness Have Been Linked Since Ancient Times -- Are We Starting To Find Out Why?

Gifted Prisoners

One Way or Another -- CO Needs To Comply with Olmstead, Parity, & Network Adequacy -- There's A Lot of Overlap

4/15/2018

This blog contains a lot of references and resources on:

Olmstead
Parity, and
Medicaid Network Adequacy

CMS has really been ramping it up because State's aren't in compliance. These concerns about Olmstead, Parity, and Medicaid Network Adequacy are incredibly re-enforcing.

We don't think Colorado is currently in compliance with Parity or Network Adequacy.

Probably by May 1, 2018, we will provide the State our Draft Letter to CMS.

We do believe we are looking @ a CMHIP [Colorado Mental Health Institute @ Pueblo] Style Emergency in Mental Health & Substance Use Treatment that has been building for over half a century.

The Final Federal Rule on the MHPAEA and Medicaid was not issued until 2016
All State Medicaid Programs were to be in compliance with the MHPAEA by October 2017 based on self-reporting.
This is a really complicated confusing law and it appears that our own Colorado Department of Health Care Policy & Financing has had its struggles.
Specifically, HCPF does not appear to appreciate its legal obligation to change or modify rate setting in order to comply with parity.
That is like a really BIG DEAL and one of the reasons CO is NOT in Compliance with parity.

Medicaid Serious Mental Illness [SMI] & Substance Use Disorder [SUD] Patient Access: Parity, Network Adequacy, Reimbursement -- We Think it is a CMHIP-Style Emergency

US Department of Justice Guidance on Title II of the ADA and Olmstead (2011)

7. May the ADA and Olmstead require states to provide additional services, or services to additional individuals, than are provided for in their Medicaid programs?

A: A state’s obligations under the ADA are independent from the requirements of the Medicaid program.

Providing services beyond what a state currently provides under Medicaid may not cause a fundamental alteration, and the ADA may require states to provide those services, under certain circumstances.

For example, the fact that a state is permitted to “cap” the number of individuals it serves in a particular waiver program under the Medicaid Act does not exempt the state from serving additional people in the community to comply with the ADA or other laws.

https://orchidadvocacy.org/doj-letter-and-qa-on-adas-integration-mandate-and-doj-enforcement----even-if-you-know-a-lot-about-olmstead----if-you-have-not-read-this----you-probably-will-want-to.html

Updated Minnesota Court Ordered Olmstead Plan

So what are we saying with this video - we're not going to drive by anybody's house.

What we are saying is that one way or another we're going to figure out a way to bring CO in compliance with the Olmstead, Parity, & Medicaid Network Adequacy & -- CMS [Centers for Medicare & Medicaid Services] could do a lot of the heavy lifting for people with disabilities.

Americans with Disabilities Act (ADA) (1990)

Title I - Employment
Title II - Public Services
Title III - Public Accommodations
Title IV - Telecommunications
Title V - Miscellaneous

https://askjan.org/links/adasummary.htm

Olmstead v. LC (US Supreme Court 1999)

Unnecessary Institutionalization of people with disabilities amounts to Discrimination under the ADA.

States have a defense if they have “a comprehensive, effectively working plan for placing qualified persons with mental disabilities in less restrictive settings, and a waiting list that moved at a reasonable pace not controlled by the State’s endeavors to keep its institutions fully populated.”

https://www.olmsteadrights.org/about-olmstead/

US Department of Justice Guidance on Title II of the ADA and Olmstead (2011)

12. What is an Olmstead Plan?
A: An Olmstead plan is a public entity’s plan for implementing its obligation to provide individuals with disabilities opportunities to live, work, and be served in integrated settings.

A comprehensive, effectively working plan must do more than provide vague assurances of future integrated options or describe the entity’s general history of increased funding for community services and decreased institutional populations.

Instead, it must reflect an analysis of the extent to which the public entity is providing services in the most integrated setting and must contain concrete and reliable commitments to expand integrated opportunities.

The plan must have specific and reasonable timeframes and measurable goals for which the public entity may be held accountable, and there must be funding to support the plan, which may come from reallocating existing service dollars.

The plan should include commitments for each group of persons who are unnecessarily segregated, such as individuals residing in facilities for individuals with developmental disabilities, psychiatric hospitals, nursing homes and board and care homes, or individuals spending their days in sheltered workshops or segregated day programs. [We would contend this also includes people with disabilities are insitutionalized in jails and prisons and are at great risk of institutionalization due to homelessness In fact, that is how institutionalization have been interpreted].

To be effective, the plan must have demonstrated success in actually moving individuals to integrated settings in accordance with the plan.

A public entity cannot rely on its Olmstead plan as part of its defense unless it can prove that its plan comprehensively and effectively addresses the needless segregation of the group at issue in the case.

Any plan should be evaluated in light of the length of time that has passed since the Supreme Court’s decision in Olmstead, including a fact-specific inquiry into what the public entity could have accomplished in the past and what it could accomplish in the future.

https://orchidadvocacy.org/doj-letter-and-qa-on-adas-integration-mandate-and-doj-enforcement----even-if-you-know-a-lot-about-olmstead----if-you-have-not-read-this----you-probably-will-want-to.html

Medicaid Network Adequacy & Stakeholder Liaisons

4/14/2018

We Would like to see Integrated Physical & Mental Health Care Liaisons for two large and under-served populations that are costing the Counties, the State, and Hospitals enormous amounts of money:

Coloradans who are involved with the Criminal Justice System on Medicaid or eligible to be on Medicaid upon release from incarceration.
Coloradans who are homeless.

Our understanding is that Colorado does have a Tribal Liaison or is in the process of getting one.

Such Liaisons could be critical in helping to determine Network Adequacy for historically poorly served populations.

Previous utilization patterns and trends in FFS [Fee for Service] and managed care programs are not, however, perfect predictors of service use under managed care in the future because:

(1) they will not reflect changes in care delivery patterns due to managed care and

(2) the populations served under FFS or other states’ managed care programs may differ in important ways from current enrollees in the program.

Previous utilization data for Medicaid and CHIP beneficiaries, delivered through either FFS or managed care, also can be misleading if access to care was inadequate, as indicated by such measures as:

*low immunization rates,

* poorly controlled chronic conditions [Mental Illness & Substance Use Disorder are often poorly controlled chronic conditions, especially among people who could be released from incarceration or who are homeless] or

*high incidents of emergency department (ED) visits or avoidable hospitalizations. [We would include incarcerations and homelessness as well.]

Therefore, although previous trends in service use are useful as a baseline for estimating future service needs, they should be adjusted to reflect the effects of:

(1) benefit changes, such as greater use of mental health services due to the mental health parity requirements;

(2) delivery system reforms designed to encourage greater use of appropriate primary and preventive care; and

(3) differential risk arising from voluntary versus mandatory enrollment into managed care.

Stakeholder input.

To better understand the characteristics and health care needs of the various populations that will enroll in Medicaid, states should consult with local stakeholders and advocates to learn about health care needs and service utilization patterns.

State departments of health, mental health, aging and disability, and labor employ individuals with expertise in
the needs of special enrollee populations and specific provider types, services, and geographic
areas.

Wisconsin’s Medicaid agency, for example, worked with the state public health department to identify acute access barriers, such as high rates of homelessness, when developing a local pilot program.

The state used this information to develop standards reflecting regional health needs, and shared the data with managed care plans so they could develop appropriate
provider networks and consider the social determinants of health.

States with large populations of individuals who have specific health needs may want to designate
an internal liaison to help identify specific access challenges that these groups face.

New Mexico, for example, appoints a tribal liaison who works closely with Indian Health Service and other providers who predominantly serve the state’s American Indian community. [We think Colorado has a Tribal Liaison or is in the process of getting one].

The tribal liaison attends the state’s quarterly Native American Technical Advisory Committee work group and is responsible for advocating for American Indians and communicating their health care needs to the Medicaid
department

Medicaid Serious Mental Illness [SMI] & Substance Use Disorder [SUD] Patient Access: Parity, Network Adequacy, Reimbursement -- We Think it is a CMHIP-Style Emergency

4/13/2018

CMS and the Feds are moving in the right direction with Parity and Network Adequacy.
For Mental Health & Substance Use Disorders -- that's a tall order in an area that was already workforce challenged.
Community Mental Health & Substance Use maybe facing a similar crisis that CMHIP faced last summer.
The question is -- "Is this an EMERGENCY?" Just as in the case of CMHIP -- we would say it is an emergency.
We really want to thank the CO Dept. of Health Care Policy & Financing for all their progressive work -- which is ENORMOUS.
So there are A LOT of good things with the Accountable Care Collaboratives and the Regional Accountable Entities
So we're focusing on the negative because it is extremely serious and needs to be addressed immediately -- not because that is all there is in CO Medicaid -- there are a lot of great things.
  We've already had Colorado's largest substance use treatment provider [Arapaho House] close, largely due to inadequate reimbursement.
We have people who are incarcerated and homeless because there is not network adequacy for intensive mental health treatments such as Assertive Community Treatment and or drug treatment.
We have to have an analysis of all relevant populations to determine Network Adequacy & Parity -- & that includes:

Coloradans with mental illness & substance use issues being released from county jails and state prisons;
Coloradans with mental illness & substance use issues who are homeless;
Coloradans with mental illness & substance use issues in nursing homes;
Coloradans with mental illness & substance use issues in the Mental Institutes; and
Coloradans with mental illness & substance use issues in the Community.

And of course the services have to be person-centered and strength-based if they are to be relevant to the person.

"The MHPAEA final rule provides examples of factors considered to be NQTLs, such as designing behavioral health network tiers, standards for admission to a provider network, and reimbursement rates that restrict behavioral health benefits in ways that create disparity with medical benefits."

Parity & Network Adequacy
p. 93-94

Parity. States are developing network adequacy standards at the same time they are attempting to implement the 2008 Mental Health Parity and Addictions Equity Act (MHPAEA) as it applies to Medicaid managed care plans (§438 Subpart K and §457.1201(1)).

MHPAEA requires parity between mental health or SUD benefits and medical/surgical benefits with respect to financial requirements and treatment limitations. Importantly, the final rule prohibits managed care plans from imposing “non-quantitative treatment limitations” (NQTLs), which limit the scope or duration of benefits in ways not framed numerically without meeting certain criteria.

Plans may apply NQTLs to mental health and SUD benefits if the same limits on the scope or duration of benefits are comparable to, and applied no more stringently than, factors they use to limit medical surgical/benefits [§438.910(d) and §457.496(d)].

The MHPAEA final rule provides examples of factors considered to be NQTLs, such as designing behavioral health network tiers, standards for admission to a provider network, and reimbursement rates that restrict behavioral health benefits in ways that create disparity with medical benefits.

Additional guidance and other sources also suggest that, depending on how they are framed, certain network adequacy standards could constitute a prohibited NQTL

We Don't Have A Problem With A Medicaid Work Requirement -- BUT If It Is Not Individually Tailored --- It Is Going To Be A Disaster

4/12/2018

It can sound really "cushy" to systematically tailor employment to the individual. The truth is if someone is not working in this great economy --- there are probably some pretty complicated reasons for that -- some type of invisible disability being high on the list:

Learning Disabilities
Mental Illness
Brain Injury
Developmental Disability
Over-excitabilities associated with High IQ;
Etc.

The question of whether something is good or bad is often a question of context. It is largely matching the person to the context or job with appropriate guidance on "reasonable accommodations."

We can't expect individuals or employers to figure this out by themselves.

When I was growing up, my Dad was very concerned that by the time I was 40 I would have a heart attack due to my Type A personality.

Well, I didn't have a heart attack -- but @ 44 I did have a psychotic break. Now I think there were many factors in that:

high altitude
sleep apnea
poor diet
daily glass of wine (I think I'm too short for that)
genetic components
adult trauma
rejection sensitive dysphoria, &
over-excitabilities

I think working with peers in Mental Health is more often than not working with highly intelligent people whose sensitivity and over-excitabilities are largely misunderstood.

At the same time, some of those over-excitabilities seem to be damaging our immune systems. What made us seem so smart can destroy our cognitive abilities if we're not careful.

It is very hard for people who don't have those "over-excitabilities" to relate to them and it can appear "crazy" -- so then the person with the "over-excitabilities" is isolated and becomes even more "over-excitable" -- there is probably more damage to the immune system and more likelihood that that person will develop an honest to goodness mental disorder.

I think we want to be open with these "over-excitabilities."

With respect to jobs, we need to recognize that people come in complex packages:

If they are not challenged enough -- they may likely get bored and depressed;
If the challenges are too great -- they are likely to get overly anxious and even afraid
For people who aren't "average," the job suit is going to need tailoring to FIT in our society.

If that "tailoring to fit" is done, we have no objection to a Medicaid work requirement.

P.S. People ARE NOT LAZY. If that's what it looks like -- let's dig deeper and find out what is REALLY going on.

Go With the Flow

The Quality of Employment Matters for Mental Health

Mashable.com

Being in poor-quality work which, perhaps, is boring, routine or represents underemployment or a poor match for the employee's skills is widely regarded as a good way for the unemployed to remain connected to the labor market — and to keep the work habit. But Butterworth's data contradicts this.

The HILDA data shows unambiguously that the psychosocial quality of bad jobs is worse than unemployment. Butterworth looked at those moving from unemployment into employment and found that:

Those who moved into optimal jobs showed significant improvement in mental health compared to those who remained unemployed.

Those respondents who moved into poor-quality jobs showed a significant worsening in their mental health compared to those who remained unemployed.

http://mashable.com/2014/12/17/bad-jobs-mental-health/#zDqltmx2Ksq0

[I love this video because in it includes observations of Dr. James McCabe @ the Institute of Psychiatry in London on bipolar disorder: who gets it -- people who are intellectually above-average in the humanities, below-average, the main thing NOT average.]

[Colorado Vocational Rehabilitation]

[Temple Grandin]

Genius & Madness Have Been Linked Since Ancient Times -- Are We Starting To Find Out Why?

Gifted Prisoners

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Val's Blog

Hallelujah!!!!!!!-- SB 18-250 -- Jail Based behavioral Health Services, Screening, Coordination with transitional care coordination

With Medicaid Network Adequacy, CMS is Potentially bringing disability Enforcement to the Wild, wild States

OrCHID after Almost 5 years -- Where Are We & WHere are We Going

Rough Draft on Our Thoughts on Network Adequacy for CO Medicaid

CMS, Network Adequacy, & the Possibility of More Consistent Enforcement for People with Disabilities

Overexcitabilities, Sensitivities & Prone to Mental Health Issues --It is Time for the Mental Health Profession To Wake Up to the Complexities & "Special Needs" of People Who Are "Gifted"

One Way or Another -- CO Needs To Comply with Olmstead, Parity, & Network Adequacy -- There's A Lot of Overlap

Medicaid Network Adequacy & Stakeholder Liaisons

Medicaid Serious Mental Illness [SMI] & Substance Use Disorder [SUD] Patient Access: Parity, Network Adequacy, Reimbursement -- We Think it is a CMHIP-Style Emergency

We Don't Have A Problem With A Medicaid Work Requirement -- BUT If It Is Not Individually Tailored --- It Is Going To Be A Disaster

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