Blair County HealthChoices

Transcription

1 Blair County HealthChoices Executive Summary Fiscal Year Ten-Year Edition County Commissioners Bruce Erb, Chair Terry Tomassetti, Vice-Chair Ted Beam, Secretary Prepared October 2017

2 HEALTHCHOICES HealthChoices is the Commonwealth of Pennsylvania s mandatory Medicaid managed care program administered by the Department of Human Services (DHS). This integrated and coordinated health care delivery system was introduced by the Commonwealth to provide medical, psychiatric, and substance abuse services to Medical Assistance (Medicaid) recipients. Broad-based coordination is required to meet the complex needs of high risk populations in the HealthChoices managed care program and assure appropriate access, service utilization, and continuity of care for persons with serious mental illness and/or addictive diseases. The unique structure of county administered behavioral health and human service delivery systems and the counties experience in administering behavioral health services, led to county governments being offered the right-of-first opportunity to enter into capitated contracts with the Commonwealth to manage their local HealthChoices programs. As of July 1, 2007, Blair County accepted the right-of-first opportunity to manage the local program and entered into a full-risk capitation contract with the Commonwealth. The County formed a 501(c)3 nonprofit corporation called Central PA Behavioral Health Collaborative, Inc. d/b/a Blair HealthChoices, which manages the local program. Beginning on July 1, 2010, Blair HealthChoices assumed full-risk for the capitation contract with DHS. During Fiscal Year , Blair HealthChoices continued to sub-contract with its behavioral managed care organization partner, Community Care Behavioral Health Organization. Services provided by Community Care included care management, provider network development, quality assurance, member services, and claims management. Blair HealthChoices provides oversight and monitoring of all of Community Care s activities to ensure full compliance with its contract with DHS. As of March 2012, Blair HealthChoices became a Certified Utilization Review Entity and now provides person-centered care management for HealthChoices members with more complex needs. County Commissioners Bruce Erb, Chairperson Terry Tomassetti, Vice-Chairperson Ted Beam, Secretary Current Board of Directors Steve Williamson, Chairperson Donna Gority, Vice Chairperson Kathleen Wallace, Secretary/Treasurer Commissioner Erb Nancy Imes Paul Querry Management Group Amy Marten-Shanafelt, Executive Director Lori Craine, Director of Clinical Services Jeffrey Harvey, Director of Finance Tina Burman, Executive Assistant Kelly Corl, Care Management Supervisor Ron Barrett, Clinical Care Manager Tera Kelleher, Clinical Care Manager Michelle Wellwood, Clinical Care Manager Lindsay Wagner, Quality Improvement Coordinator Rebecca Brandt, Office Support Worker 2

3 Enrollment Blair HealthChoices 10-Year Eligibility Trend Eligible Members on Last Day of Year FY through FY ,165 29,664 25,940 21,243 21,510 22,376 22,603 22,578 22,585 22,908 FY FY FY FY FY FY FY FY FY FY Categories of Aid: Temporary Assistance to Needy Families (TANF) Assistance to families with dependent children who are deprived of the care or support of one or both parents. Healthy Beginnings (HB) Assistance for women during pregnancy and the postpartum period. Modified Adjusted Gross Income (MAGI) The Affordable Care Act made the tax concept of Modified Adjusted Gross Income (MAGI) the basis for determining Medicaid and CHIP eligibility for nondisabled, nonelderly individuals, effective January 1, Newly Eligible Medicaid expansion category for adults, ages 21 and older, with household incomes up to 138% of the Federal Poverty Level (FPL), effective January 1, Supplemental Security Income without Medicare Assistance for people who are aged, blind, or determined disabled for less than two years. Supplemental Security Income with Medicare Assistance for people who are aged, blind or determined disabled for over two years. 3

4 Member Demographics Male 13, % Female 15, % At the end of Fiscal Year there were 29,664 Blair County residents enrolled in the HealthChoices Program. Other % African American 1, % Caucasian 27, % Age 65 and older 1, % Age 0-5 3, % Age , % Age , % Age , % Age , % NOTE: Percentages may not sum to 100% due to rounding. Age , % 4

5 Services HealthChoices members are eligible to receive in-plan services offered by their choice of at least two service providers as well as additional services that have been approved for use by the Blair HealthChoices Program. In-Plan Services: Inpatient Psychiatric Hospitalization Inpatient Drug & Alcohol Detoxification, Treatment, Non-Hospital Rehabilitation, and Halfway House Psychiatric Partial Hospitalization Services Outpatient Mental Health and Drug & Alcohol Counseling Laboratory and Diagnostic Services Medication Management and Clozapine Support Psychiatric Evaluation and Psychological Testing Residential Treatment Facilities for Adolescents (RTF) Behavioral Health Rehabilitative Services for Children and Adolescents (BHRS) Methadone Maintenance Targeted Case Management Crisis Intervention Family Based Mental Health Services Peer Support Services Mobile Mental Health Treatment Supplemental Services: Drug & Alcohol Level of Care Assessment Drug & Alcohol Intensive Outpatient Drug & Alcohol Targeted Case Management Drug & Alcohol Partial Hospitalization Psychiatric Rehabilitation Children s Services enrolled as Program Exceptions Summer Therapeutic Activities Program (STAP) Autism After School Program Music Therapy School-Based Rehabilitation Program Community and School-Based Behavioral Health Behavioral Health Home Dual Diagnosis Treatment Team Crisis Stabilization Residential Unit for Dual Diagnosis Evidence-Based Modalities: Multi-Systemic Therapy (MST) Functional Family Therapy (FFT) Parent Child Interaction Therapy Trauma-Focused Cognitive Behavioral Therapy Eye Movement Desensitization and Reprocessing Therapy Critical Time Intervention Applied Behavioral Analysis-Autism Support Services 5

6 Male 4, % Members Served Utilization Age , % Age % Age % Age , % Age , % Female 4, % Age % Age , % Male $16,954, % Expenditures Age $5,501, % Age 65+ $139, % Age 0-5 $1,189, % Age 6-12 $6,037, % Female $14,755, % Age $11,974, % Age $1,258, % Age $5,608, % Fiscal Year as of October 2017 Members Served: 9,031 Claims Payments: $31,709,991 Alternative Payment Arrangement (APA) APA Amount Paid: $ 1,588,131 P4P Amount Paid: $ 215,000 Total Expenditures: $33,513,122 Notes: Percentages may not sum to 100% due to rounding. Charts do not include amounts paid through APA or P4P 6

7 Utilization by Level of Care Members Served Outpatient MH 6, % RTF % BHRS 1, % Community Support 2, % Outpatient D&A 2, % Outpatient MH $5,550, % ** Other-Supplemental 2, % Expenditures RTF $1,142, % D&A Rehabilitation % Inpatient MH % BHRS $4,995, % Fiscal Year as of October 2017 Members Served: 9,031 Claims Payments: $31,709,991 Alternative Payment Arrangement (APA) APA Amount Paid: $ 1,588,131 P4P Amount Paid: $ 215,000 Total Expenditures: $33,513,122 Community Support $4,335, % Outpatient D&A $4,171, % **The Other service category is comprised of supplemental services, such as Drug & Alcohol Assessments, Intensive Outpatient, Partial Hospital, Case Management as well as Children s Services Program Exceptions. ** Other-Supplemental $2,820, % Inpatient MH $4,907, % D&A Rehabilitation $3,787, % Notes: Percentages may not sum to 100% due to rounding. Charts do not include amounts paid through APA or P4P 7

8 Mental Health Diagnoses Members Served Post Traumatic Stress Disorder % Schizophrenia/Psychotic Disorders % Adjustment Disorders 1, % ** Other Mental Health Disorders 1, % Anxiety Disorders 1, % Attention Deficit/Hyperactivity Disorders 1, % Depressive/Mood Disorders 2, % Fiscal Year as of October 2017 MH Members Served: 7,668 Total Expenditures: $22,936,347 Post Traumatic Stress Disorder $1,074, % Conduct/Oppositional Defiant Disorders % Expenditures Autism Spectrum Disorders % Bipolar Disorders 1, % Schizophrenia/Psychotic Disorders Adjustment Disorders $1,683,515 $1,405, % Anxiety Disorders 7.3% $1,141, % ** Other Mental Health Disorders $2,130, % Attention Deficit/Hyperactivity Disorders $2,494, % Autism Spectrum Disorders $2,339, % Depressive/Mood Disorders $5,879, % Conduct/Oppositional Defiant Disorders $1,478, % Bipolar Disorders $3,308, % **Other Mental Health disorders include dementia, delirium, organic psychotic or non-psychotic conditions, personality disorders, eating disorders, sleep disorders, tic disorders, child abuse, intellectual disability, mental disorders due to unknown causes, and transient organic mental disorders. Notes: Percentages may not sum to 100% due to rounding. Charts do not include amounts paid through APAs. 8

9 Drug & Alcohol Diagnoses Members Served Opioid Use Disorders 1, % ** Other Psychoactive Drug Use Disorders % Alcohol Use Disorders % Fiscal Year as of October 2017 DA Members Served: 2,475 Total DA Expenditures: $8,773,644 Cocaine Use Disorders % Cannabis Use Disorders % Expenditures Opioid Use Disorders $5,841, % ** Other Psychoactive Drug Use Disorders $556, % Alcohol Use Disorders $1,454, % Cocaine Use Disorders $149, % Cannabis Use Disorders $771, % **Other Drug & Alcohol disorders include drug or alcohol psychosis, drug or alcohol withdrawal, amphetamine abuse/dependence, hallucinogen abuse/dependence, inhalant abuse/dependence, sedative-hypnotic/anxiolytic abuse/dependence, and polysubstance abuse/dependence. Notes: Percentages may not sum to 100% due to rounding. Charts do not include amounts paid through APAs. 9

10 ** Other-Supplemental % Youth Members Served Included in the Youth category are all HealthChoices members under age 18 and all members involved in BHRS or RTF services Inpatient MH % D&A Rehabilitation % Outpatient 2, % Community Support % Fiscal Year as of October 2017 Youth Served: 2,752 Total Expenditures: $13,424,971 BHRS 1, % Expenditures RTF $1,142, % RTF % **The Other service category is comprised of supplemental services, such as Drug & Alcohol Assessments, Intensive Outpatient, Partial Hospital, Case Management as well as Children s Services Program Exceptions. Outpatient $2,060, % BHRS $4,995, % ** Other-Supplemental $496, % Inpatient MH $1,383, % D&A Rehabilitation $686, % Community Support $2,661, % Notes: Percentages may not sum to 100% due to rounding. Charts do not include amounts paid through APAs. 10

11 Blair HealthChoices Ten-Year Comparison $80,000, Behavioral Health HealthChoices Impact vs. the Fee-For-Service Model $70,000, $60,000, $50,000, $40,000, $30,000, $20,000, $10,000, $ Projected Fee-for-Service Behavioral Health HealthChoices Total Members Served by Level of Care FY vs. FY ,632 9,031 RTF Outpatient MH 3,287 6,333 Outpatient D&A 1,307 2,089 Other-Supplemental 1,055 2,576 Inpatient MH D&A Rehabilitation Community Support 1,371 2,542 BHRS 1,052 1,049-1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000 FY FY

12 Blair HealthChoices Ten-Year Comparison Outpatient MH $2,373,043 11% Amount Paid by Level of Care FY RTF $1,871,955 9% Outpatient D&A $978,202 5% Other-Supplemental $308,135 1% BHRS $8,824,037 42% Inpatient MH $3,083,681 15% D&A Rehabilitation $790,538 4% Community Support $2,654,894 13% Outpatient MH $5,550,030 17% Amount Paid by Level of Care FY RTF $1,142,454 4% BHRS $4,995,102 16% Outpatient D&A $4,171,700 13% Community Support $4,335,824 14% Other-Supplemental $2,820,401 9% Inpatient MH $4,907,330 15% D&A Rehabilitation $3,787,151 12% Notes: Percentages may not sum to 100% due to rounding. Charts do not include amounts paid through APAs. 12

13 Opiate Epidemic Impact Ten-Year Comparison 1,800 Members with Opioid Disorders Served FY vs. FY ,600 1,549 1,561 1,400 1,200 1, Under Age 18 Age 18 and Older Total FY FY $7,000,000 Payments for Services for Opioid Disorders FY vs. FY $6,000,000 $5,772,312 $5,841,754 $5,000,000 $4,000,000 $3,000,000 $2,000,000 $1,301,314 $1,303,516 $1,000,000 $- $2,202 $68,442 Under Age 18 Age 18 and Older Total FY FY

14 Blair HealthChoices High-Risk Care Management Blair HealthChoices became its own Certified Utilization Review Entity in March Beginning with 55 members, Blair HealthChoices High Risk Care Managers now serve 513 adults and children with complex needs. Inpatient Mental Health and Drug & Alcohol 30-Day Readmissions FY through FY % 18% 17% 16% 16% 14% 12% 11% 12% 14% 12% 14% 12% 10% 10% 9% 8% 6% 9% 7% 9% 6% 6% 7% 7% 7% 6% 4% 2% 3% 4% 3% 4% 3% 3% 4% 4% 3% 3% 4% 0% FY FY FY FY FY FY FY FY FY FY MH Readmission Rate D&A Readmission Rate MH-D&A Distinct Members Readmitted Out-of-Home Placements (RTF and CRR Host Homes) Distinct Members Admitted FY through FY FY FY FY FY FY FY FY FY FY FY Distinct Members Admitted 14

15 Consumer Family Satisfaction The Department of Human Services (DHS) and Blair HealthChoices values and encourages the input of consumers and families in all aspects of the HealthChoices Program and incorporates into all quality improvement efforts. In addition, we encourage input from consumers, persons in recovery, and families regarding the services and supports received in the mental health and drug and alcohol service system. Consumer and family feedback helps inform Providers, counties and Behavioral Health Managed Care Organizations (BH-MCO) about how services can support recovery for adults, resilience in children and adolescents and be more effective. Consumers and families have specialized knowledge and sensitivity about how respect, dignity and responsiveness of services can affect the process of recovery and preserve resilience. Members are more likely to feel safe in describing their experience with someone who is not their service Provider. Soliciting feedback on satisfaction with services empowers consumers and families and allows them to have a greater role in determining the quality of behavioral health care and recommending system improvements. Therefore, DHS requires Primary Contractors to implement a comprehensive approach for the measurement of consumer/family satisfaction by organizing a Consumer and Family Satisfaction Team (CFST). Below is a summary of the information collected. Adult - Member Access Benchmark Survey Quarter 1st 2nd 3rd 4th YTD Prior Surveys = (N) Made aware of different services & given a choice 90% 89% 88% 83% 83% 86% 75% Made aware of different providers & given a choice 90% 83% 82% 77% 87% 82% 69% Able to get help within an acceptable amount of time 90% 96% 95% 91% 96% 94% 90% Adult - Provider Recovery Oriented Treatment Experiences Benchmark Survey Quarter 1st 2nd 3rd 4th YTD Prior Surveys = (N) Provider asked me what my goals would be to achieve a happy life (CCISC) 90% 88% 93% 92% 89% 91% 90% Provider helped me identify triggers for replase 90% 88% 90% 90% 87% 89% 86% Provider helped me develop a plan to prevent relapse 90% 87% 88% 84% 89% 88% 85% Provider teaching me skills that are helpful to me (CCISC) 90% 86% 92% 87% 94% 89% n/a Provider acknowledges/rewards me for even small steps towards my goals 90% 92% 94% 82% 96% 93% 85% Provider helps me connect/reconnect to community resources/natural supports. * 90% 74% 83% 87% 89% 79% 71% Encouraged to use consumer-run programs (ROSI) 90% 81% 88% 84% 87% 85% 69% Provider talked to me about a (WRAP) Wellness Recovery Action Plan 90% 47% 67% 66% 79% 60% 36% Provider talked to me about a Mental Health Advance Directive 90% 30% 55% 31% 53% 39% 26% I feel like my provider listens to me 90% 95% 93% 90% 91% 93% n/a I feel like I have a say in treatment. 90% 92% 95% 90% 85% 92% n/a I feel like my provider empowers me 90% 90% 89% 84% 87% 88% n/a n/a = question not previously asked. Wording on some questions slightly changed Adult - Treatment Outcomes Benchmark Survey Quarter 1st 2nd 3rd 4th YTD Prior Surveys = (N) I deal more effectively with daily problems 90% 94% 87% 86% 98% 90% 81% I feel more hopeful about the future 90% 94% 88% 77% 100% 91% 88% I believe I am recovering 90% 90% 84% 83% 92% 87% 85% I feel that treatment is working 90% 96% 85% 90% 98% 91% 90% Parent-Family - Access to Services Benchmark Survey Quarter 1st 2nd 3rd 4th YTD Prior Surveys = (N) We were made aware of and given provider choice for service 90% 91% 94% 92% 86% 91% 82% We were made aware of and given choice of different services 90% 91% 89% 85% 86% 88% 85% Able to get helpi needed within an acceptable amount of time 90% 95% 98% 85% 100% 95% 88% 15

16 Consumer Family Satisfaction Parent-Family - Access to Services Benchmark Survey Quarter 1st 2nd 3rd 4th YTD Prior Surveys = (N) We were made aware of and given provider choice for service 90% 91% 94% 92% 86% 91% 82% We were made aware of and given choice of different services 90% 91% 89% 85% 86% 88% 85% Able to get helpi needed within an acceptable amount of time 90% 95% 98% 85% 100% 95% 88% Parent /Caregiver -Provider Recovery Oriented Treatment Experiences Bench Agree/Strongly Agree Survey Quarter 1 st 2 nd 3 rd 4 th YTD Prior Surveys = (N) I can count on my treatment provider to be there when I need them 90% 92% 97% 92% 86% 92% 89% I was actively involved /developing my child's treatment goals 90% 95% 97% 92% 100% 96% 96% I believe my child's treatment plan is easy to understand* 90% 95% 97% 92% 100% 96% 97% I believe my child's treatment plan is easy to put into action 90% 89% 95% 92% 100% 94% 89% My child is receiving all the services he/she needs 90% 89% 95% 92% 100% 94% 83% Child is able to apply treatment experiences at home, community & school 90% 78% 84% 85% 100% 87% 66% I feel provider is blaming me when setbacks occur in child's treatment <10% 11% 3% 8% 0% 5% 11% I know places to call or go in the community to continue to get support 90% 86% 92% 85% 86% 87% 75% Provider acknowledges even small steps toward achieving child's goals 90% 84% 92% 92% 100% 92% 90% Provider talks to me & my child about how to stay well after treatment 90% 70% 69% 88% 58% 71% 76% I know someone else who shares my experiences and supports me 90% 62% 60% 85% 43% 62% 78% Parent/Caregiver - Treatment Outcomes Benchmark Survey Quarter 1st 2nd 3rd 4th YTD Prior Surveys = (N) Child deals more effectively with daily problems 90% 87% 87% 85% 86% 68% 73% Child s behavioral health is improving 90% 78% 74% 77% 86% 78% 76% My child's social skills are improving 90% 84% 79% 77% 76% 72% 76% All Surveyors employed by the CFST are also consumers or family of consumers. All CFST results are collected via telephone or face to face and reported on each quarter. The results are shared with our Member Advisory Committees, Provider Advisory Committee, and our Clinical/Quality Improvement Committee. Providers are given their results directly and are asked to submit a Quality Improvement Plan annually to address the areas below the benchmark. We have also developed several specialized surveys that allow us to assess and analyze the impact of specific service delivery concerns. All surveys are completed using a proportional-stratified sample with a 95% confidence level. Above 90% Benchmark Satisfactory Between 85%-89% - Requires Monitoring Below 85% - Requires Action Bold 3% plus or minus change in percentage from last quarter 16

17 Complaints and Grievances 1312 Authorization Denials Fiscal Years through A service may be denied in full, a lesser amount of the service may be approved, or a different level of care may be authorized. Only a small percentage of authorization requests are totally denied FY FY FY FY FY FY FY FY FY FY Complaints Fiscal Years through Blair HealthChoices closely monitors complaints filed by HealthChoices members. Only a small number of complaints were filed during the fiscal year and each was resolved to the satisfaction of the involved member Complaints FY FY FY FY FY FY FY FY FY FY

18 Complaints and Grievances 235 Level One Grievances Fiscal Years through Members who are dissatisfied with treatment decisions may opt to file grievances to have the decisions changed. There are two grievance levels and an external review process. Additionally, a member may also choose to file a request for a Fair Hearing at any point during the grievance process FY FY FY FY FY FY FY FY FY FY Level Two Grievances Fiscal Years through L2 FY FY FY FY FY FY FY FY FY FY

19 Terminology AUTHORIZATION A process that is related to the payment of claims by which a provider receives approval from CCBHO to provide a particular service. Authorizations typically limit the number of units and the time in which the service can be provided. If a service requires authorization for payment, the lack of authorization will result in an unpaid claim. BEHAVIORAL HEALTH REHABILITATION SERVICES FOR CHILDREN AND ADOLESCENTS (BHRS) The behavioral health component for Early Periodic Screening, Diagnosis and Treatment, are services to children through the age of 21 years old designed to develop individual specific plans to care for social and emotional disturbances. CAPITATION A set amount of money received or paid out; it is based on membership rather than on services delivered and is usually expressed in units of PMPM (per member per month) or PMPD (per member per day). Under the HealthChoices program, capitation rates vary by categories of assistance. CLAIMS A request for reimbursement for a behavioral health service. COMPLAINT A process by which a consumer or provider can address a problem experienced in the HealthChoices program. CONSUMER HealthChoices enrollees on whose behalf a claim has been adjudicated for behavioral health care services during the reporting period. DENIAL A denial is defined as a determination made by a managed care organization in response to a provider s request for approval to provide services of a specific duration and scope which (1) disapproves the request completely; (2) approves provision of the requested service(s), but for a lesser scope or duration than requested by the provider; (an approval of a requested service which includes a requirement for a concurrent review by the managed care organization during the authorized period does not constitute a denial); or (3) disapproves provision of the requested service(s), but approves provision of an alternative service( s). DIAGNOSIS A behavioral health disorder based on DSM or ICD diagnostic criteria. DIAGNOSTIC CATEGORIES Subgroups of behavioral health disorders. This report contains the following groupings: Bipolar Disorders a group of mood disorders that characteristically involve mood swings. This group includes: Bipolar I Disorder, Bipolar II Disorder, Bipolar Disorder Not Otherwise Specified, Mood Disorder, and Mood Disorder Not Otherwise Specified. Depressive Disorders a group of mood disorders that includes Major Depressive Disorder, Dysthymia, and Depressive Disorder Not Otherwise Specified. Schizophrenia and Psychotic Disorders a collection of thought disorders such as Schizophrenia, Schizoaffective Disorder, Schizophreniform Disorder, and Psychotic Disorder Not Otherwise Specified. Anxiety Disorders a group of disorders that includes: Panic Disorder, Social Phobia, Posttraumatic Stress Disorder, Obsessive Compulsive Disorder, Generalized Anxiety Disorder, and Anxiety Disorder Not Otherwise Specified. Adjustment Disorder the development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors. Impulse Control Disorders includes Intermittent Explosive Disorder, Trichotillomania, and Impulse Control Disorder Not Otherwise Specified. 19

20 ADHD and Disorders in Children includes Attention Deficit Hyperactivity Disorder, Conduct Disorder, Oppositional Defiant Disorder, and Disruptive Behavior Disorder Not Otherwise Specified. Other Mental Health Disorders includes Tic Disorders, Learning Disorders, Communications Disorders, and Motor Skills Disorders. Substance Abuse/Dependence Disorders there are 11 classes of substances: alcohol, amphetamines, caffeine, cannabis (marijuana or hashish), cocaine, hallucinogens, inhalants, nicotine, opioids (heroin or other narcotics), PCP, and sedatives/hypnotic/ anxiolytics. DSM The Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. This manual provides a diagnostic coding system for mental and substance abuse disorders. ENROLLMENT The number of Medicaid recipients who are active in the Medical Assistance program at any given point in time. FAIR HEARING APPEAL A grievance process through which a HealthChoices member can file a written appeal, to the Department of Human Services, regarding a behavioral health care service decision. GRIEVANCE The process by which a consumer addresses a problem with a decision made about his/her behavioral health care service. This may include denial of a service, approving less service than what was requested, or approving a level of care different from that requested. There are two levels of grievances and an external review process. 1st Level Grievance: An issue which is subject to review within 24 hours for urgent care and 30 days for non-urgent care. 2nd Level Grievance: A 2nd Level Grievance may be filed if the member has not received satisfactory resolution to the 1st Level Grievance. The 2nd Level Grievance Committee reviews the issue within 30 days. BLAIR COUNTY PENNSYLVANIA HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) This is a Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives the Health and Human Services Department of the federal government the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. MEMBER Eligible Medical Assistance recipients enrolled in the HealthChoices program during the reporting period. RESIDENTIAL TREATMENT FACILITY (RTF) A self-contained, secure, 24-hour psychiatric residence for children and adolescents who require intensive clinical, recreational, educational services and supervision. UTILIZATION The amount of behavioral health care services used by Medicaid recipients. Utilization is based on encounter (paid claims) information. External Review: An External Review can be requested after the 2nd level Grievance decision. This process is independent from the managed care organization or the primary contractor. 20