Blair County HealthChoices Annual Report Fiscal Year 2013-2014 County Commissioners Terry Tomassetti, Chair Diane L. Meling, Vice-Chair Ted Beam, Secretary Prepared January 2015
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, to assure appropriate access, service utilization, and continuity of care for persons with serious mental illness and/or addictive diseases, is required to meet the complex needs of high risk populations in the HealthChoices managed care program. 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. As of July 1, 2010, Blair HealthChoices assumed full-risk for the capitation contract with DHS. During Fiscal Year 2013-2014, Blair HealthChoices sub-contracted with a behavioral managed care organization, 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 Terry Tomassetti, Chairperson Diane L. Meling, Vice-Chairperson Ted Beam, Secretary Current Board of Directors Kathleen Wallace, Chairperson Nancy Imes, Vice-Chairperson Bob Kuntz, Secretary/Treasurer Donna Gority Commissioner Diane L. Meling Jeff Sefchok Steve Williamson Management Group Amy Marten-Shanafelt, Executive Director Lori Craine, Director of Clinical Services Jeffrey Harvey, Director of Finance DeAnne Belles, Quality Improvement Coordinator Tina Burman, Administrative Assistant Ron Barrett, Clinical Care Manager Kelly Corl, Clinical Care Manager Tera Kelleher, Clinical Care Manager 2
Enrollment Blair HealthChoices Eligibility Trend Eligible Members on Last Day of Year FY 2007-2008 through FY 2013-2014 22,968 22,603 22,578 22,609 22,376 21,510 21,243 FY 2007-2008 FY 2008-2009 FY 2009-2010 FY 2010-2011 FY 2011-2012 FY 2012-2013 FY 2013-2014 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. State Only General Assistance State funded program for individuals and families whose income and resources are below established standards and who do not qualify for the TANF program. This includes the Categorically Needy (CNO) and Medically Needy Only (MNO) groups. 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, 2014. 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
Member Demographics Other 383 1.7% African American 1,105 4.8% At the end of Fiscal Year 2013-2014 there were 22,968 Blair County residents enrolled in the HealthChoices Program. Caucasian 21,480 93.5% TANF/MAGI/Healthy Beginnings 12,853 56.0% Medically Needy 73 0.3% SSI without Medicare 5,869 25.6% Male 10,233 44.6% Categorically Needy 674 2.9% SSI with Medicare 3,499 15.2% Female 12,735 55.4% Age 45 to 64 3,949 17.2% Age 65 and older 1,304 5.7% Age 00 to 05 3,730 16.2% Age 06 to 12 4,051 17.6% Age 21 to 44 6,144 26.8% Age 18 to 20 1,274 5.5% Age 13 to 17 2,516 11.0% Blair HealthChoices Executive Summary - Fiscal Year 2013-2014 4
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 Multi-Systemic Therapy (MST) Functional Family Therapy (FFT) Summer Therapeutic Activities Program (STAP) Autism After School Program Music Therapy New service addition in FY 13-14: School Based Rehabilitation Program 5
Utilization Members Served Male 3,196 47.3% Female 3,564 52.7% Age 45-64 1,318 19.5% Age 65+ 118 1.7% Age 0-5 317 4.7% Age 6-12 1,144 16.9% Age 13-17 890 13.2% Fiscal Year 2013-2014 Members Served: 6,760 Total Expenditures: $26,969,958 Age 21-44 2,650 39.2% Expenditures Age 18-20 323 4.8% Male $14,624,135 54.2% Female $12,345,823 45.8% Age 45-64 $3,781,670 14.0% Age 65+ $139,894 0.5% Age 0-5 $1,339,077 5.0% Age 6-12 $6,635,540 24.6% Age 21-44 $7,641,402 28.3% Age 18-20 $1,343,365 5.0% 6 Age 13-17 $6,089,010 22.6%
Utilization by Level of Care Members Served Outpatient MH 5,003 42.2% RTF 31 0.3% BHRS 990 8.4% Community Support Svcs 1,995 16.9% Outpatient D&A 1,140 9.6% Fiscal Year 2013-2014 ** Other-Supplemental Svcs 1,888 15.9% D&A Rehabilitation 268 2.3% Inpatient MH 524 4.4% Members Served: 6,760 Total Expenditures: $26,969,958 Outpatient MH $3,377,998 12.5% Expenditures RTF $1,832,213 6.8% BHRS $6,497,343 24.1% **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 D&A $2,586,238 9.6% ** Other-Supplemental Svcs $2,806,141 10.4% Inpatient MH $4,151,386 15.4% D&A Rehabilitation $1,628,497 6.0% Community Support Svcs $4,090,142 15.2% 7
Mental Health Diagnoses Members Served ** Other MH 469 5.0% Schizophrenia / Psychosis 470 5.0% ADHD/Conduct 1,691 17.9% Depression 2,618 27.8% Adjustment 1,224 13.0% Fiscal Year 2013-2014 MH Members Served: 6,040 Total MH Expenditures: $22,387,679 Bipolar 1,265 13.4% Autism Spectrum 417 4.4% Expenditures Anxiety 1,274 13.5% ** Other MH $327,182 1.5% Schizophrenia / Psychosis $1,748,989 7.8% ADHD/Conduct $5,189,832 23.2% Depression $5,398,930 24.0% Adjustment $1,810,213 8.1% Anxiety $685,448 3.1% Bipolar $3,196,002 14.3% Autism Spectrum $4,031,084 18.0% **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. 8
Drug & Alcohol Diagnoses Members Served ** Other DA 295 17.7% Opioid 955 57.3% Alcohol 237 14.2% Cocaine 17 1.0% Cannabis 164 9.8% Fiscal Year 2013-2014 DA Members Served: 1,442 Total DA Expenditures: $4,582,279 Expenditures ** Other DA $699,697 15.3% Opioid $3,194,553 69.7% Alcohol $340,308 7.4% Cannabis $311,311 6.8% Cocaine $36,410 0.8% **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. 9
Average Cost per Member Blair HealthChoices Average Cost per Member by Age Group 2013-14 Age 0-5 $4,224 $5,025 $4,952 $4,778 Age 6-12 $5,800 $6,737 $7,249 $7,221 Age 13-17 $7,062 $7,153 $6,842 $7,609 Age 18-20 $2,997 $3,461 $4,311 $4,159 Age 21-44 $2,737 $2,799 $2,735 $2,884 Age 45-64 $2,934 $2,807 $2,954 $2,869 Age 65+ $967 $1,096 $1,186 $1,677 Blair HealthChoices Average Cost per Member by Level of Care 2013-14 BHRS $8,306 $8,130 $4,528 $6,563 Community Support Services $2,024 $1,995 $2,038 $2,050 Drug & Alcohol Rehabilitation $5,438 $5,656 $7,469 $6,076 Inpatient Mental Health $7,523 $7,584 $7,528 $7,922 Other-Supplemental Services $1,080 $1,417 $1,112 $1,486 Outpatient Drug & Alcohol $2,048 $2,185 $2,018 $2,269 Outpatient Mental Health $771 $743 $721 $675 RTF $48,708 $52,599 $63,822 $59,104 10
Outpatient MH 5,003 42.2% Youth Members Served RTF 31 0.3% BHRS 990 8.4% Included in the Youth category are all HealthChoices members under age 18 and all members involved in BHRS or RTF services Outpatient D&A 1,140 9.6% ** Other-Supplemental Svcs 1,888 15.9% Community Support Svcs 1,995 16.9% D&A Rehabilitation 268 2.3% Inpatient MH 524 4.4% Fiscal Year 2013-2014 Youth Served: 2,381 Total Expenditures: $14,790,931 ** Other-Supplemental Svcs $431,986 2.9% Inpatient MH $1,513,377 10.2% Outpatient $1,468,099 9.9% Expenditures RTF $1,832,213 12.4% **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. BHRS $6,497,343 43.9% D&A Rehabilitation $211,272 1.4% Community Support Svcs $2,836,641 19.3% 11
Quality Assurance Authorization Denials by Quarter Fiscal Years through 2013-14 87 77 46 48 35 36 38 27 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. 31 38 32 27 37 35 25 32 2013-14 2013-14 2013-14 2013-14 Complaints by Quarter Fiscal Years through 2013-14 11 Blair HealthChoices closely monitors complaints filed by HealthChoices members. Only a small number of complaints were filed during the 2013-2014 fiscal year and each was resolved to the satisfaction of the involved member. 9 7 6 5 5 4 4 3 3 2 2 2 2 1 0 2013-14 2013-14 2013-14 2013-14 12
Quality Assurance Level One Grievances by Quarter Fiscal Years through 2013-14 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. 47 42 21 20 11 15 9 16 11 9 12 18 10 8 6 2 2013-14 2013-14 2013-14 2013-14 Level Two Grievances by Quarter Fiscal Years through 2013-14 22 12 10 6 3 2 4 0 2 1 1 3 1 2 2 0 2013-14 2013-14 2013-14 2013-14 13
Terminology AUTHORIZATION A process that is related to the payment of claims by which a provider receives approval from Community Care 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. 14
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. 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. 15
Blair HealthChoices 1906 NORTH JUNIATA STREET HOLLIDAYSBURG, PA 16648 814-696-5680 http://www.blairhealthchoices.org