OLR Research Report


January 28, 2013

 

2013-R-0045

THE CONNECTICUT BEHAVIORAL HEALTH PARTNERSHIP

 

By: Nicole Dube, Associate Analyst

This report provides a brief overview of the Connecticut Behavioral Health Partnership.

SUMMARY

The Connecticut Behavioral Health Partnership (BHP) is an integrated, public behavioral health system operated by the departments of children and families (DCF), mental health and addiction services (DMHAS), and social services (DSS). It provides coordinated, individualized behavioral health services and supports to children and adults enrolled in HUSKY A (Medicaid), HUSKY B (State Children's Health Insurance Program (SCHIP)), HUSKY C (Aged, Blind, and Disabled), HUSKY D (Low-Income Adults), Charter Oak Health Plan, and DCF's Limited Benefit program. In 2012, program membership totaled 783,204, including 453,478 adults and 329,726 children.

The departments contract with ValueOptions, a national managed behavioral health care company, to serve as the BHP's administrative services organization (ASO). Among other things, ValueOptions authorizes services, helps the departments develop and maintain an adequate provider network, and collects member and provider data.

The BHP provides a continuum of behavioral health services and supports ranging from outpatient psychotherapy and extended day treatment to methadone maintenance and inpatient psychiatric hospitalization. Providers must receive prior authorization from ValueOptions for many services, including higher level of care services such as inpatient psychiatric hospitalization, inpatient detoxification, and intensive outpatient services.

ValueOptions can deny a service request for administrative or medical necessity reasons. A member can appeal any denial by completing an internal appeal process with ValueOptions and, if still unsatisfied, an administrative hearing held by either DSS (for HUSKY A, C, and D members), the insurance department (for HUSKY B and Charter Oak Health Plan members), or DCF (for Limited Benefit Program members).

The BHP Oversight Council advises the three departments on the BHP's planning and administration. It is comprised of legislators, behavioral health consumers and advocates, medical and behavioral health practitioners, state agencies, and insurers. Among other things, the council reviews and makes recommendations on contracts between the departments and ValueOptions, program services, appeals procedures, and rate setting.

BHP

History

In 2006, the departments of children and families and social services, along with a legislatively mandated oversight council, formed the BHP. Initially, the partnership managed the funding and delivery of behavioral health services for children and families enrolled in HUSKY A, HUSKY B, and DCF's Limited Benefit Program (Medicaid-ineligible children with specialized behavioral health needs). In 2008, the BHP expanded to include Charter Oak Health Plan enrollees.

In 2010, the state received federal approval to expand its Medicaid program to include low-income, childless adults (referred to as “LIA”). In response, DMHAS joined the partnership in 2011, and program eligibility further expanded to include the state's two adult Medicaid populations: Medicaid C (Aged, Blind, and Disabled) and Medicaid D (LIA).

ValueOptions, a national managed behavioral health care company, was initially selected, and continues to serve, as the partnership's ASO. It contracts with the departments to provide administrative assistance regarding clinical, utilization, and quality management. Among other things, it (1) authorizes and monitors services and levels of care, (2) helps the departments develop and maintain an adequate provider network, (3) collects data on BHP members and providers, and (4) conducts an annual quality management evaluation of its effectiveness as the partnership's ASO (CGS 17a-22p).

In addition, each department designates a BHP director to coordinate department and ASO activities to help (1) alleviate hospital emergency room crowding, (2) reduce unnecessary admissions and lengths of stay in hospitals and residential treatment settings, (3) increase available outpatient services, and (4) promote a community-based, recovery-oriented system of care (CGS 17a-22i).

An eight-member clinical management committee develops the BHP's clinical guidelines. Members have experience or expertise in behavioral health and are appointed by the three departments and the BHP Oversight Council (see below)(CGS 17a-22k).

Program Goals

The BHP was created to increase access to individualized, family-centered behavioral health services and supports that allow low-income children and adults with behavioral health issues to remain in their homes and communities.

According to its website, the BHP's primary goals include:

1. providing access to a more complete, quality, and effective system of community-based behavioral health services and supports;

2. supporting recovery and access to quality community services that reduce unncessary care in the most restrictive settings;

3. improving care coordination through enhanced communication and collaboration within the behavioral health delivery system and with the medical community;

4. improving network access and quality; and

5. recruiting and retaining traditional and non-traditional providers.

The law also specifies that the partnership must (1) improve administrative oversight and efficiencies, (2) monitor member outcomes and provider performance, and (3) maximize federal revenue to fund these services by investing any federal revenue and savings achieved from reducing residential services and increasing community-based services (CGS 17a-22h).

Membership

In 2006, the BHP ended its first calendar year (CY) with 316,168 members, including 225,719 children and 90,449 adults. Membership continued to increase each year, particularly in 2011 when the program expanded to include the state's adult Medicaid populations. In CY 2012, membership totaled 783,204, including 453,478 (57.9%) adults and 329,726 (42.1%) children. See Figures 1 and 2 for detailed membership data.

Figure 1: BPH Adult Membership CYs 2011-2012

Source: ValueOptions CY 2012 Enrollment Data

Figure 2: BPH Child Membership CYs 2008-2012

Source: ValueOptions CY 2012 Enrollment Data

Services

The BHP provides a continuum of behavioral health services and supports ranging from outpatient, individual therapy to inpatient psychiatric hospitalization. ValueOptions maintains a database of network providers, who must be Medicaid-certified. Table 1 provides a list of covered services.

Table 1: BHP Services

Hospital Outpatient Services

Outpatient, intensive outpatient, extended day treatment, and partial hospitalization services

Psychiatric evaluation and treatment services related to a medical diagnosis

Freestanding Outpatient Medical Clinic Services

Evaluation and treatment services provided by a licensed behavioral health professional if the member has a primary behavioral health diagnosis

 

Freestanding Mental Health and Ambulatory Substance Use Clinic Services

All services regardless of the member's diagnosis

 

Emergency and Inpatient Hospital Services

23-hour observation

All psychiatric hospital services and associated charges, regardless of the member's diagnosis

Inpatient and residential detoxification (i.e., inpatient hospital or inpatient freestanding clinic services) if the member has a primary diagnosis of substance use

Inpatient general hospital services if the member has a primary behavioral health diagnosis

Professional psychiatric services provided in an emergency department by a community psychiatrist that meets certain qualifications

Professional services related to a behavioral health diagnosis provided during a medical hospital stay

Crisis stabilization beds

 

Individual Practitioner Services (by a licensed behavioral health provider)

Outpatient evaluation and treatment services if the member has a primary behavioral health diagnosis

Psychological and developmental testing if the member has a primary behavioral health diagnosis

Consultation and case management services if the member has a primary behavioral health diagnosis

 

Home Health Agency Services

DSS must authorize and manage these services if (1) they are required solely for a medical diagnosis, (2) they are required for medical and behavioral health diagnoses and the medical diagnosis is primary, or (3) the member's treatment needs cannot be safely managed by the psychiatric nurse or aide

ValueOptions must authorize and manage these services if (1) they are required solely for a behavioral health diagnosis, (2) they are required for medical and behavioral health diagnoses and the behavioral health diagnosis is primary, (3) the member's behavioral health issues are so complex they cannot be safely managed by the medical nurse or aide, or (4) autism is one of the member's first three diagnoses

Other Services

Methadone maintenance services

Adult mental health group homes

School-based health center treatment and assessment services

DCF residential treatment centers and mental health group homes

Electro convulsive therapy

Psychiatric residential treatment facilities

Source: Connecticut BHP Member Handbook, http://www.ctbhp.com/members/info/Member_Handbook-English.pdf, last visited on January 24, 2013.

Prior Authorization

BHP providers must receive prior authorization from ValueOptions for many services to ensure that those paid for are medically necessary and appropriate. A ValueOptions care manager reviews demographic and clinical information to ensure that the member meets eligibility and level of care requirements for the particular service requested.

Care managers must issue an authorization decision to BHP providers within certain timeframes, depending on the level of care requested and whether it requires a psychiatrist's clinical review. For example, higher level of care services that do not require a psychiatrist's review, such as inpatient psychiatric hospital admissions, inpatient detoxification, and intensive outpatient services, require an authorization decision within one hour. In contrast, lower level of care services, such as group home, residential treatment, and extended day treatment services, require an authorization decision within one business day. Other lower level of care services, such as inpatient hospital or outpatient psychotherapy, do not require prior authorization.

Service Denials and Appeals

ValueOptions may deny a provider's service request for either administrative or medical necessity reasons. Administrative denials generally occur when a provider fails to follow administrative requirements, including pre-authorization protocols. Medical necessity denials occur when the appropriateness or medical necessity of a requested service is not demonstrated. The total number of administrative and medical necessity denials from CY 10 to CY 11 increased by 78.1% and 89.4% respectively. ValueOptions attributes this increase to the significant rise in BHP's adult membership resulting from its 2011 program expansion. It notes that the number of medical necessity denials for children has steadily decreased over recent years and expects a similar result for the adult population over time.

A member can appeal any denial within 60 days of receiving a denial letter. ValueOptions reviews the initial appeal request and issues a decision within 30 days of receiving it. If still unsatisfied, the member can request an administrative hearing held by either DSS (for HUSKY A, C, and D members), the insurance department (for HUSKY B and Charter Oak Health Plan members), or DCF (for Limited Benefit Program members).

BHP OVERSIGHT COUNCIL

The BHP Oversight Council advises DCF, DMHAS, and DSS on the BHP's planning and administration. Created in 2005, the council is comprised of legislators and their designees, behavioral health consumers and advocates, medical and behavioral health practitioners, state agencies, and insurers. Table 2 lists the council's membership.

The council reviews and makes recommendations on, among other things:

1. contracts between the departments and ASOs to assure ASO decisions are based solely on clinical management criteria developed by the BHP's clinical management committee;

2. behavioral health services provided under Medicaid and S-CHIP to ensure federal revenues are maximized;

3. periodic reports from the BHP on services, finances, outcomes, and achievment of the partnership's goals;

4. the departments' member and provider appeal procedures; and

5. policies related to coordinated delivery of physical and behavioral health services for BHP members (CGS 17a-22j to -22o).

In addition, the council reviews all department proposals regarding initial BHP service rates, existing rate reductions, and rate methodology changes. If the council does not recommend acceptance of the proposal, it can forward its recommendation to the Human Services, Appropriations, and Public Health committees. These committees must hold a joint public hearing on the council's recommendation and issue their own recommendations to the departments within 90 days after the council received the rate proposal. The departments must make every effort to incorporate the recommendations of both the council and the legislative committees when setting rates (CGS 17a-22o).

Table 2: 2013-2014 BHP Oversight Council Appointments

Appointing Authority

Statutory Designation

Governor

Two representatives of general or specialty psychiatric hospitals

Governor

Two parents of children who have a behavioral health disorder or received child protection or juvenile justice services from DCF

Senate President Pro Tempore

Two parents of children who have a behavioral health disorder or received child protection or juvenile justice services from DCF

Senate President Pro Tempore

One health policy and evaluation expert

Senate President Pro Tempore

One advocate for children with behavioral health disorders

House Speaker

Two representatives of general or specialty psychiatric hospitals

House Speaker

One adult with a psychiatric disability

House Speaker

One advocate for adults with psychiatric disabilities

Senate Majority Leader

One advocate for adults with substance use disorders

Senate Majority Leader

One school-based health clinic representative

House Majority Leader

One Medicaid primary care provider

House Majority Leader

One child psychiatrist serving HUSKY children

Senate Minority Leader

One provider of community-based services for children with behavioral health problems

Senate Minority Leader

One Medicaid Medical Assistance Program Oversight Council member

House Minority Leader

One provider of community-based psychiatric services for adults

House Minority Leader

One children's residential treatment provider

 

Public Health, Human Services, and Appropriations Committee chairs and ranking members or their designees

BHP Oversight Council Chairs

One representative of a home health care agency providing behavioral health services

BHP Oversight Council Chairs

One provider of substance use disorder treatment services

BHP Oversight Council Chairs

One adult in recovery from a psychiatric disability

BHP Oversight Council Chairs

One parent of family member of an adult with a serious behavioral health disorder

Nonvoting Ex-Officio Members

DCF Commissioner

Commissioner or her designee

Department of Development Services Commissioner

Commissioner or his designee

Department of Education Commissioner

Commissioner or his designee

DMHAS Commissioner

Commissioner or her designee

Judicial Branch Chief Court Administrator

One Court Support Services Division representative

Office of Policy and Management (OPM) Secretary

One representative

State Comptroller

One representative

 

One representative of each ASO under contract with DSS to service Medicaid, HUSKY A and B, and Charter Oak Health Plan members

RESOURCES

Connecticut Behavioral Health Partnership website, http://www.ctbhp.com/, last visited on January 24, 2013.

Connecticut Behavioral Health Partnership Provider Manual,

http://www.ctbhp.com/providers/prv_manual.htm, last visited on January 24, 2013.

Connecticut Behavioral Health Partnership 2011 Quality Management Program Evaluation.

Connecticut Behavioral Health Partnership Oversight Council website, http://www.cga.ct.gov/ph/BHPOC/, last visited on January 24, 2013.

ND:car