Behavioral Health Services Budget Updates
Frequently Asked Questions for Providers
December 21, 2010 | December 10, 2010 | October 15, 2010 | September 27, 2010 | August 27, 2010 | August 13, 2010 | July 30, 2010 | July 28, 2010 | July 9, 2010 | July 2, 2010 | June 25, 2010 | June 18, 2010 | June 4, 2010 | June 2, 2010 | May 28, 2010 | May 17, 2010
Frequently Asked Questions for Providers – December 21, 2010
Q: ARS 150-2(A)(1) lists a drivers license can be use as verification for US Citizenship/lawful presence. However, the DBHS guidance documents do not include this information. Please clarify when a driver's license is acceptable in the RBHA/provider verification process for eligibility for AHCCCS.
A: ADHS/DBHS is issuing the following clarification regarding verification of citizenship/lawful presence for persons who apply for or are currently receiving behavioral health services as part of the public health system in Arizona:
For AHCCCS eligibility, behavioral health members/applicants are required to verify BOTH citizenship/lawful presence and identity. Lists A, B and C contain the lists of documents acceptable for this purpose. ADHS/DBHS requires that all persons requesting behavioral health services be screened for AHCCCS eligibility via Health-e-Arizona.
If a person cannot provide acceptable documentation for AHCCCS eligibility or is found to be ineligible for AHCCCS for any other reason, an Arizona drivers license or Arizona non-operating identification license issued after 1996 is acceptable as verification of citizenship for Non-Title XIX covered services (see A.R.S. § 1-502(A)(1)).
If you have any questions or need further information, please contact Joann Hatton at joann.hatton@azdhs.gov or (602) 364-4556.
Frequently Asked Questions for Providers – December 10, 2010
Q: If children in CPS/DES custody referred through the 72 hour behavioral health response require ongoing behavioral health services, who is responsible for payment if TXIX eligibility is pending?
A: For medically necessary behavioral health services after the 72 hour period but before TXIX eligibility has been approved, the behavioral health provider should contact CMDP Member Services for TXIX eligibility determination. Specifically, please dial 602-351-2245, press 1 (for English), press 2 (if you are a provider), and press 1 for Member Services (assistance with eligibility). If TXIX is approved retroactively, the RBHA will be responsible for payment, if TXIX eligibility is not approved CMDP will be responsible for payment. Regardless of who is responsible for payment, it is important that all parties remain involved in the coordination of care for the child.
Frequently Asked Questions for Providers – October 15, 2010
Q: Do we allow NTXIX services/crisis to out of state residents?
A: Yes, if an-out of state individual has a crisis episode in Arizona, the NTXIX (out-of-state) member would be handled like any other Arizonan NTXIX member, and receive the services. ADHS/DBHS State Funded Crisis dollars would be the payment of last resort and all attempts to apply for TXIX should be followed. In addition, the provider should exhaust all other payors, including coverage from the client's home state. The provider would provide necessary crisis services and follow third party liability requirements upon identifying responsible payors.
Q: What is the expectation for the Behavioral Health Provider to provide services while waiting for official CMDP eligibility when CPS places a child in an out- of-home placement situation?
A: All children referred from CPS are required to be seen through the 72-hour response process. If the child is T19 eligible, T19 funds are to be used, if not, crisis funding can be used or CMHS or SAPT funding as applicable. If the child becomes T19-enrolled after the placement, the RBHA is responsible for the prior period coverage if the placement is medically necessary and meets the Prior Authorization criteria. If the child does not become T19-enrolled, residential services are not a covered benefit. For instructions on providing services after the 72-hour response, please see this flow chart.
Frequently Asked Questions for Providers – September 27, 2010
Q: Are the RBHAs expected to develop crisis plans for Non-Title XIX SMI persons who become eligible for services subsequent to 07/01/10 and continue to update the crisis plans of Non-Title XIX SMI persons currently eligible for services?
A: As stated in the "ADHS/DBHS Guidelines to the RBHAs and Providers for Services to Non-Title XIX Members with Serious Mental Illness," released on May 3, 2010, the RBHAs must conduct a psychiatric assessment for all Non-Title XIX SMI members. The initial psychiatric assessment and all follow-up visit progress notes must document treatment plan goals and the member's progress. Furthermore, the assessment must document discussions and referrals to other community resources and supports and coordination of care efforts related to primary care, inpatient settings, crisis service providers and other community providers. As such, crisis planning is a component of the assessment process and crisis planning efforts should be documented in the initial assessment and in all follow-up visit progress notes -- using the available billing codes.
Q: Are assessments covered for non-TXIX persons when they are conducted to determine SMI eligibility? What funding can be used to pay for this?
A: Yes, assessments are covered for non-TXIX persons when they are conducted to determine SMI eligibility. Non-TXIX medication funding can be used for the assessment, even if it results in the member not being determined to be SMI. Please see the Guidelines for RBHAs and Providers: Billing Codes for the Non-Title XIX SMI Medication Benefit
and Policy Clarification - SMI Determination Timeframes for more details.
Frequently Asked Questions for Providers – August 27, 2010
Q: What is the rationale for ADHS/DBHS' decision to not cover room and board costs for Level II, III and Home Care Training To Home Care Client (HCTC)?
A: Federal regulations prohibit the use of Medicaid funds to pay for room and board costs. CMHS grant dollars will be available to offset these costs for individuals under the age of 18 and SAPT grant dollars will be available to offset these costs for certain adult SAPT priority population members in Level II, III and HCTC settings. Otherwise, room and board costs will be the responsibility of the member if the member has the ability to pay. This change is consistent with the policy of the Arizona Long-Term Care System (ALTCS) in that room and board has never been covered for that population.
Q: Does ADHS/DBHS fund room and board room and board costs for Level II, III and HCTC for children?
A: CMHS grant dollars (and SAPT grant dollars for certain priority population members) will be available to offset these costs for individuals under the age of 18.
Q: Does ADHS/DBHS fund room and board costs for Level II, III and HCTC for adults?
A: SAPT grant dollars will be available to offset these costs for certain adult SAPT priority population members. Otherwise, room and board costs will be the responsibility of the member. This change is consistent with the policy of the Arizona Long-Term Care System (ALTCS) in that room and board has never been covered for that population. Please view the SAPT FAQs
Frequently Asked Questions for Providers – August 13, 2010
Q: Will there be a separate medication formulary for each T/RBHA? How about a separate medication formulary for crisis services?
A: No, there will be only 2 DBHS formularies. One is for TXIX/XXI eligible individuals and one is for non-TXIX/XXI eligible individuals. While RBHAs can add to the RBHA version of the TXIX/XXI formulary, RBHAs cannot add to the non-TXIX/XXI formulary. For people presenting for crisis services, providers should use the TXIX/XXI or non-TXIX/XXI formulary, depending on the recipient's eligibility status. These formularies can be found in the Provider Manual.
Q: Has ADHS developed any guidelines regarding service provision to Non-XIX consumers who are receiving Court-ordered treatment?
A: Court Ordered Evaluation and Treatment is addressed in the DBHS guidance document on Services for Non-TXIX members with SMI.
Q: Provider Manual Section 3.5, Third Party Liability and Coordination of Benefits, states that RBHAs should pick up the cost of third party co-payments if the co-payment is greater than the ADHS/DBHS $3 co-payment. However, if someone has Medicare Part D, shouldn't the Part D plan be billed first before using Title XIX or state funds?
A: RBHAs will pick up a third party co-payment only for medications or services that are also covered in the service package for Non-Title XIX/XXI persons determined SMI. It is still the expectation that third party payors are billed prior to using Title XIX/XXI or state funds (please note for Title XIX/XXI eligible individuals with Medicare Part D coverage, Title XIX/XXI funds cannot be used to cover medication co-payments). ADHS/DBHS expects RBHAs to pick up the co-payment to address discrepancies between Non-Title XIX/XXI persons determined SMI without third party liability (TPL) who would pay a $3 co-payment versus Non-Title XIX/XXI persons determined SMI with TPL who may be required to pay greater than $3 for the same benefits.
Q: What do we do if the TPL for NTXIX services is less than the contracted rate for the service?
A: If the service is part of the Non-TXIX service package and the reimbursement from TPL is less than the contracted rate between provider and RBHA, Non-TXIX funds can be used to make up the difference in the payment.
Q: If a person applying for behavioral health services says he/she is not a U.S. citizen, should I ask if he/she is in the country legally or illegally and report accordingly?
A: No. The Health – e- Arizona prescreen module does not include that question and DBHS does not require employees of the RBHA or its contracted providers to ask that question of an applicant. The document, ADHS/DBHS Guidelines to the RBHAs and Providers for Reporting Requirements in A.R.S. § 1-502, states that a person must VOLUNTARILY state either verbally or in writing that they are not lawfully in the U.S. for a report to be required. RBHA and provider staff is expected to use the language provided as part of the Health e Arizona module for screening purposes to ensure that the necessary information is obtained, while avoiding unnecessary risks of engaging in discriminatory conduct in the process of soliciting the information. A list of accepted documents for verification is included with the guidance and is also located on the Health e Arizona module for use. If a person does not have any of the documents listed, they must be entered as OTHER—no further information is needed.
Q: Does DBHS deport persons reported to them for violations of federal immigration law per A.R.S. § 1-502?
A: No. DBHS sends valid reports of violations of federal immigration law to Immigration and Customs Enforcement pursuant to ARS 1-502. DBHS does not investigate submitted reports nor does the agency initiate deportation.
Q: Can RBHAs or Providers charge a co-payment for SAPT-funded treatment services?
A: RBHAs or Providers are prohibited from charging a co-payment, or any other fee, for substance abuse treatment services funded by the SAPT Block Grant. See SAPT FAQs at /bhs/pdf/SAPTFAQs.pdf .
A: When a member is made TXIX, the effective date is the first of the month in which the application was submitted. Any services provided during the prior period of coverage in which the member was assessed a fee can be reprocessed. The provider should refund the fee and submit a claim/encounter to the RBHA instead.
Frequently Asked Questions for Providers – July 30, 2010
Q: Is the Non-Title XIX/XXI medication only benefit applicable to both Non-Title XIX/XXI persons determined SMI with third party liability (TPL) and Non-Title XIX/XXI persons determined SMI without TPL?
A: The Non-Title XIX/XXI medication only benefit is applicable to all Non-Title XIX/XXI persons determined SMI, including Non-Title XIX/XXI persons determined SMI with TPL. However, providers are expected to bill Medicare or other third parties prior to using state-only funds. There may be circumstances where a Non-TXIX/XXI, person determined SMI is not able to access the same coverage for benefits through their third party that they can access through the ADHS/DBHS medication-only benefit. As such, the changes to PM Section 3.5 are intended to ensure that Non-TXIX/XXI, persons determined SMI are not paying more when using third party payors for the same benefit they can get through ADHS/DBHS
Q: The ADHS/DBHS Covered Behavioral Health Services Guide currently only allows case management and assessment services to be billed when the provider has had telephone contact with a behavioral health recipient, but the guidance document regarding the medication-only benefit package for Non-Title XIX/XXI persons with SMI includes telephone contact by an RN or LPN as part of the benefit. Are providers allowed to bill T1002 and T1003 for telephone contact?
A: Yes, providers are allowed to bill T1002 and T1003 for medically necessary services provided over the telephone. When the ADHS/DBHS Covered Behavioral Health Services Guide is updated, the General Core Billing Limitations will include nursing support as a service that can be provided over the telephone.
Q: ADHS/DBHS recently posted and distributed the Guidelines to RBHAs and Providers for Verifying United States Citizenship or Lawful Presence of Applicants. Should this verification process be used for all Non Title 19 recipients currently enrolled with the RBHA and/or receiving services?
A: No. The Guidance document that was posted on 7/15/10 describes the verification process for citizenship or lawful presence for all persons who apply for behavioral health services beginning July 1, 2010, who are NOT currently enrolled with a RBHA. At this time, a recipient currently receiving services as a Non-title 19 SMI, or as a recipient of the SAPT or PATH grants –does NOT need to verify citizenship or lawful presence in the U.S. DBHS will issue further guidance for those recipients who are currently enrolled and receiving services.
Q: When will D BHS issue further guidance on verification of citizenship or lawful presence in the U.S. for recipients currently enrolled as Non Title 19 SMI (not eligible for AHCCCS)?
A: ADHS/DBHS will issue further guidelines within the next few weeks.
Q: When a person is currently enrolled for the NonTitle 19 SMI limited services package requests to transfer to another RBHA, is it necessary for the receiving RBHA to verify citizenship/lawful presence for the recipient upon transfer?
A: No. The normal transfer process – as set out in PM 3.17, Transition of Persons will still apply. DBHS will issue further guidance for those recipients who are currently enrolled and receiving services within the next few weeks.
Frequently Asked Questions for Providers – July 28, 2010
Q: As a CSA (Community Service Agency) are we allowed to provide services to NT19 consumers?
A: While providers (CSAs as well as Clinics) may provide uncompensated care, providers that offer free services to NT19 consumers must properly document and account for the source of funds used to pay for these free services in order to be able to demonstrate that T19 funds were not used to service NT19 consumers. Failure to demonstrate that T19 funds are used solely to serve T19 consumers opens the door to potential allegations of fraud.
Q: If the member is SMI, non19 and picks up his medications, what is the time frame within which the copay should be paid?
A: If the person will be paying the $3 ADHS/DBHS co-payment, he/she will pay at the time of the psychiatric assessment or psychiatric follow-up appointment. In this case, no co-pay will be collected at the pharmacy. If the person has a co-payment for his/her medication that is less than the ADHS/DBHS co-payment, he/she will pay the TPL co-payment at the pharmacy.
Q: If a member doesn't have the 3 dollar co pay at the time of the next assessment or follow-up appointment, does he/she lose the opportunity to stay on meds? Does he/she get seen for the BHMP visit - or does he/she return when he/she actually has the funds?
A: No. The ADHS/DBHS co-payment is for the entire medication-only benefit package. The ADHS/DBHS co-payment is a "soft" co-payment, which means that a person cannot be denied services for nonpayment of his/her co-payment.
Q: Also, is the 3 dollar copay applicable to each refill, or only when there is an appointment? For instance, the member picks up scripts on 7/13 and 8/12, but his appointment is on 8/14 - does he pay 3 dollars or 6 dollars. Also, if (due to side effects) he is seen for medication management three times, does he pay 3 dollars each time - or just one time?
A: Because the ADHS/DBHS co-payment is applicable to the entire benefit that Non-Title XIX/XXI, SMI individuals receive, the co-payment will not be collected for every service or when individuals go to the pharmacy for medications. The only time NTXIX, SMI individuals will be asked to pay their co-payment is at the time of their psychiatric assessment or psychiatric follow-up appointments. However, the policy is flexible in that providers can set up different payment options for individuals, based on individual needs.
Q: The $3 co-pay applies to state-only non-TXIX with SMI for all services rendered in the med benefit (psychiatrist, nursing, formulary) unless the person chooses to remain on brand and pays for it or has fallen into the Part D donut hole and is on a generic or agrees to go to a generic. Is this correct?
A: The $3 is the ADHS/DBHS co-payment for utilizing the generic medication-only benefit. When it is the case that a person with TPL has a co-payment for the same medication that is on the ADHS/DBHS Non-Title XIX/XXI Medication Formulary, the person will pay whichever co-payment is less (most likely, it would be the ADHS/DBHS co-payment). The Part D donut hole is tricky because the person is responsible for the full cost of medication – if the cost is picked up through ADHS/DBHS, it would hinder the person's ability to move through the donut hole (as it would not count toward the person's true out of pocket (TROOP) costs).
Q: How are RBHAs supposed to track co-payments for Non-Title XIX, SMI persons with third party coverage and apply our newly established requirements specific to the ADHS/DBHS co-payment vs. the TPL co-payment? Specifically, the issue is that the DBHS co-payment is supposed to be collected at the psychiatric assessment/follow-up visit (and our co-pay is applicable to all services in the service package), and the TPL co-pays are collected for each service/each visit to the pharmacy.
A: RBHAs will need to work with their PBMs to ensure that co-payments greater than the ADHS/DBHS $3 co-payment are picked up by the RBHA. When a person shows up for his/her psychiatric assessment or psychiatric follow-up appointment, the provider should document whether or not the person is paying any co-payment at the pharmacy. If the person is not paying any co-payment at the pharmacy, then the provider will collect the ADHS/DBHS $3 co-payment.
Q: For both Title 19 and non-Title 19 SMI persons receiving Medicare benefits and DBH mental health services, who pays for their medication when they reach the Medicare coverage gap (donut hole)?
A: Non-Title XIX/XXI persons determined SMI with Medicare Part D will be responsible for paying for their medications while in the Medicare coverage gap ("doughnut hole"). ADHS/DBHS does not cover this cost as part of the Non-Title XIX/XXI, SMI medication benefit. Because ADHS/DBHS is not a State Pharmaceutical Assistance Program (SPAP), if ADHS/DBHS were to pay for medications while a person is in the Medicare coverage gap, the payments ADHS/DBHS would make would not count toward true out of pocket costs (TROOP). TROOP is needed in order for a person to get through the Medicare coverage gap and reach catastrophic coverage. Dual eligible (people with both Medicare and Medicaid coverage) do not have a coverage gap.
Q: I'm wondering why CPT 99211 was left off of the list of recommended billing codes. 99211 is routinely used when the physician's nurse performs an injection, and billed along with the J-codes that are listed for Medicare reimbursement. The T-codes listed for nursing support medication administration are not Medicare covered services, thus are ineligible for that funding source.
A: The NT19-SMI billing codes were developed to provide the RBHAs with a way to control costs so that funding would last for the full fiscal year. As for T1002 and T1003 these codes have not been covered by Medicare since 1/1/07 so if the client has Medicare the provider would not bill them for these services.
Q: The following questions relate to Administration of Supported Housing – General Fund, #5, which states "The RBHAs shall not actively refer or place individuals in Supervisory Care Homes or unlicensed board and care facilities."
- Q1) Does this provision preclude the use of Supported Housing funds to supplement the rent of a TXIX/XXI person with SMI who has independently chosen to live in a boarding home?
A: No - RBHAs shall not actively refer or place individuals in Supervisory Care Homes or unlicensed board and care facilities, but in this scenario, the person has independently chosen to live in a boarding home.
- Q2) Does this provision preclude the continued use of Supported Housing funds after July 1, 2010, for a Non-TXIX/XXI person with SMI who were receiving supported housing services?
A: No – the ADHS/DBHS Guidelines to RBHAs and Providers for Supported Housing Services states that the RBHAs may continue to use the Supported Housing – General Fund for Non-Title XIX SMI members who were receiving supported housing services before May 3, 2010. RBHAs, however, will need to transition these individuals to alternative housing, as specified in the Guidelines.
- Q3) Are "Supervisory Care Homes" the same as ADHS licensed "Assisted Living Facilities"? Does this provision preclude the use of Supported Housing funds to supplement the rent of persons with SMI who live in ADHS licensed Assisted Living Facilities?
A: NO. According to the Guidelines, the supported housing line item does not cover room and board for residential for T19 persons with SMI. This also applies to assisted living. It is recommended that the room and board charges be modeled after AHCCCS/ALTCS sliding fee scale and become the responsibility of the individual. However, the limits around the supported housing line item will not apply to any other funding source, including county intergovernmental agreements. The RBHAs can continue to fund housing for a NT19 person using some other source of funding after July 1.
- Q4) Can we continue using Supported Housing funds while a Non-TXIX/XXI person with SMI transitions safely to another living arrangement?
A: According to the Guidelines, the supported housing line item is not to be used to fund room and board for residential treatment facilities for NT19 and the services they receive are crisis and medication. This applies to NT19 Assisted Living as well. It is recommended that the room and board charges be modeled after AHCCCS/ALTCS sliding fee scale and become the responsibility of the individual. However, the limits around the supported housing line item will not apply to any other funding source, including county intergovernmental agreements. The RBHAs can continue to fund housing for a NT19 person using some other source of funding after July 1.
Frequently Asked Questions for Providers – July 9, 2010
Q: If a client sees the provider more than one time in a day, one of the services is crisis the other is not how would you want that coded? All as crisis or not?
A: For multiple services provided on the same day, by the same provider to the same client those services must be combined together and if any of those services are crisis services, all services will be considered crisis.
Q: Are the codes listed for crisis services the only codes that can be marked as emergency and will be considered crisis?
A: Any code marked with an emergency indicator will be considered as part of the crisis package.
Q: After July 1, can we refer NT19 SMI members with Medicare or TPL to a Medicare/TPL doctor in their network (outside the T/RBHA system)?
A: For any non-TXIX SMI member with TPL, including Medicare, the T/RBHA should bill the TPL first, as the state is the payer of last resort. If a member, of their volition, chooses to disenroll from the T/RBHA and seek all behavioral health services through their TPL, that is the member's choice. However, the member should be informed that he/she is entitled to certain benefits as a result of their SMI eligibility, including set co-pays of $3. Because the co-pay through the T/RBHA system is likely lower than that through the TPL, the member may prefer to receive services through the T/RBHA system. T/RBAHS must not compel the member to disenroll and receive services through their TPL.
Q: This question is regarding the "Crisis Billing Codes" that were published 6-14-10. It is my understanding that no one other than a crisis provider can bill the codes (T1016 HO, T0116 HN, H2022, H2011 HT, S9484, and S9485). In other words, outpatient clinics cannot use crisis codes even if their client had a crisis because the crisis codes are only to be used by crisis providers. Is this accurate?
A: The guidelines presented in the "Crisis Billing Guidelines" document are to be used as a guideline for identifying crisis services. The Covered Services Guide has not changed. The provider should reference the B2 appendix to determine the billable procedures by provider type.
Q: Can a level 1 Sub Acute facility qualify as a provider under the SAPT Level IV Guidance? If so, what are the priority population requirements?
A: Yes, it could qualify; inquiries and solicitation for SAPT funding should be made to the RBHA. For Priority Population guidelines and funding restrictions please see the SAPT FAQ document, available on the ADHS/DBHS website (/bhs/pdf/SAPTFAQs.pdf).
Q: Can you please explain the crisis guidance that refers to the "23-hour crisis observation/stabilization services"? Does it apply to me even if I don't offer 23-hour observations beds in my facility?
A: The requirement does not speak to beds, facilities or any particular service delivery model. It does require RBHAs and providers to cover 23-hour crisis observation/stabilization services when medically necessary. These services can be offered in any type of licensed and clinically appropriate setting. For example, in regions that contract for Level I inpatient and sub-acute services, the 23-hour crisis observation/stabilization service can be provided there. The important point here is that RBHAs and providers make 23-hour crisis observation/stabilization services available and not that they be connected to any one facility or service delivery model. For detoxification services, Level IV rural transition settings can be used. In addition, this may be an instance when additional stabilization hours are available beyond 24 hours due to the availability of SAPT grant funding.
Q: Are ALL crisis services listed in the final benefit package meant for any individual presenting with behavioral health crisis?
A: The crisis benefit applies to "any person presenting with a behavioral health crisis in the community, regardless of Medicaid eligibility or enrollment status." It is ADHS/DBHS' expectation that all required crisis services in the benefit package (phones, mobile teams, 23-hour crisis observation/stabilization) be available to anyone presenting to the RBHA in need of such services. Enrollment with the RBHA and/or AHCCCS eligibility is not required and crisis services cannot be denied on this basis.
Frequently Asked Questions for Providers – July 2, 2010
Q: DBHS prior authorization criteria for brand name medications require evidence of a plan to transition to an alternative generic medication or find an alternative funding source. What is the standard for approval of plans to find an alternative funding source?
A: The RBHA must verify that the BHMP has a plan for securing alternative funding within the 90 day time frame.
Q: Do the requirements for the prior authorization of Risperidal Consta apply to all SMI members, including Title XIX SMI members?
A: No, DBHS' prior authorization requirements for Risperidal Consta are only required for Non-title XIX SMI members. However, specific RBHAs may already have a DBHS approved prior authorization process for Risperidal Consta for Title XIX members.
Q: What is DBHS' definition of Schizophrenic Spectrum Disorder for purpose of meeting the clinical criteria for authorization of Risperidal Consta?
A: DBHS defines Schizophrenic Spectrum Disorder as including: Schizophreniform Disorder, Schizophrenia, and Schizoaffective Disorder. Cluster A personality disorders and Bipolar I disorder are not included in this definition.
Q: Can the prior authorization request s for brand name medication be approved for less than 30 days.
A: No. Authorization criteria for brand name medication must be approved for at least 30 days, in 30-day increments and up to 90 days.
Q: Can the following medications be added to the Non-title XIX SMI formulary?
A: Any requests for adding generic forms of medications to the DBHS Non-title XIX formulary must be submitted by the RBHA through the established DBHS review process. The Non-title XIX SMI formulary requests will then be reviewed in the DBHS Pharmacy and Therapeutics Committee, and any proposed changes will be discussed with the RBHA Chief Medical Officers. Medications added to the Non-title XIX formulary will apply to all RBHAs.
Q: Is the Risperidal Consta available to any Non-title XIX SMI member presently in treatment?
A: Yes, consistent with the ADHS/DBHS Guidelines to the RBHAs and Providers for the Required Prior Authorization Process for Risperidal Consta.
Q: Are medisets covered under the limited Non-title XIX benefit package after July 1, 2010?
A: Yes. Medisets are covered and can be billed or encountered under the allowable billing codes for RNs and LPNs.
Q: NT19 clients are being informed that they can only see their doctor/NP every 90 days post July 1. Is this correct?
A: Some individuals will be seen at 90-day intervals and others will be seen more often. The BHMP is able to use the office appointments to monitor individuals more frequently than every 90 days if clinically indicated.
Q: Can providers bill retrospectively for services provided to a NT19 SMI member after June 30, 2010 who has submitted an AHCCCS application and is very likely to receive approval?
A: At the discretion of the provider, services may be provided to a member whose AHCCCS application is pending. If eligibility is determined and made retroactive to the time of the services, payment would be provided. The type of enrollment established will determine the payor (Acute Plan or RBHA). Timeliness requirements of individual RBHAs may apply.
Frequently Asked Questions for Providers – June 25, 2010
Q: Under the new non-title 19 benefits, will nursing visits at the clinics be a covered service for triage purposes regarding crisis or medication issues?
A: Yes. The registered and licensed practical nurse will assist the doctor/PA/ANP with treatment coordination. The nurse can be contacted for medication issues and treatment of crisis issues such as medication side-effects and related medical questions. The nurse will decide if questions should be relayed to the Doctor/PA/ANP. The nurse can assist the patient with a referral to the Crisis System if the patient requires an immediate assessment or evaluation.
NOTE: The following set of FAQs relate to the "Provider Manual Section 3.4, Co-payments, and Provider Manual Section 3.5, Third Party Liability and Coordination of Benefits". The updated versions of these policies are effective 7/1/10.
Q: Does ADHS/DBHS require co-payments for medications?
A: Provider Manual Section 3.4, Co-payments, states that co-payments are assessed for non-Title XIX/XXI persons determined to have a Serious Mental Illness (SMI) and are intended to be payments by the member for the entire service package (e.g., psychiatric assessments, medication management, medications). However, co-payments are only collected at the time of the psychiatric assessment and psychiatric follow up appointments. ADHS/DBHS co-payments are NOT collected for medications at the pharmacy. Co-payments do not apply to crisis services at this time.
Q: For individuals with Medicare Part D, is the RBHA required to pay Medicare Part D co-payments for generic psychotropic medications on ADHS' Formulary for NTXIX SMI members using the state-only funds allocated to the RBHAs?
A: Yes – Provider Manual Section 3.5, Third Party Liability and Coordination of Benefits, states that a Non-Title XIX/XXI person determined to have SMI who has third party insurance will be assessed either the ADHS/DBHS co-payment or the co-payment required by the third party insurer, whichever is less. T/RBHAs, therefore, are responsible for covering the difference between the ADHS/DBHS co-payment and the third party co-payment when the third party co-payment is greater than the ADHS/DBHS co-payment.
Q: Is the RBHA to pay deductibles for these members?
A: No – Provider Manual Section 3.5 states that behavioral health recipients are responsible for third party co-payments for services that are not services that ADHS/DBHS covers (see ADHS/DBHS Guidelines to the RBHAs and Providers for Services to Non-Title XIX Members with Serious Mental Illness) and third party premiums, coinsurance and deductibles, if applicable.
Q: Is the RBHA to pay other co-insurance for these NTXIX SMI members?
A: No – Provider Manual Section 3.5 specifies, as stated above, that RBHAs will cover co-payments according to the policy requirements, but premiums, coinsurance and deductibles will not be covered by the RBHAs.
Q: Are RBHAs still responsible for full cost of generic benzodiazepines.
A: Benzodiazepines continue to be a Medicare Part D excluded drug, so for individuals who are Title XIX/XXI eligible, benzodiazepines are covered through AHCCCS. For Non-Title XIX/XXI persons determined to have SMI, generic benzodiazepines will continue to be covered through the RBHA and ADHS/DBHS.
Q: What is the ADHS/DBHS co-payment on generic medications for NTXIX SMI? Is this new? A: ADHS/DBHS established a new co-payment of $3 for the medication only benefit package, which means that that the fee for the benefit is associated with all of the services in the benefit (e.g., psychiatric assessments, medication management, medications). See the scenarios below regarding how the ADHS/DBHS co-payment is applied.
Q: A Non-Title XIX person with Medicare Part D goes to the pharmacy to get generic medication. There is a deductible that the RBHA cannot pay, so member pays that. There is a co-payment of $15 after the Part D plan pays. There are no other payers. Is the ADHS/DBHS co-payment equal to the $15? And if so, is that what the member pays?
A: The person would only be responsible for the $3 co-payment, which is the ADHS/DBHS co-payment. The $3 is collected at the time of the physician visit, but the co-payment is intended to be payment by the member for his/her medication benefit. So, for this particular scenario, the RBHA would pick up the $15 medication co-pay (since it is greater than the ADHS/DBHS co-pay), and the person would pay his/her $3 at the time of the physician visit. The person would only pay $3 when showing up for his/her appointment, rather than $6 ($3 for medication and $3 for physician visit), since the co-payment is for the medication benefit as a whole, and not "attached" to the medication/service.
Q: A Non-Title XIX person determined to have SMI goes to the pharmacy to get generic medication, and the person does not have third party coverage. The RBHA pays 100% for the generic medication. What is the person's co-payment, and when is the co-payment collected?
A: The person will pay his/her $3 ADHS/DBHS co-payment at the time of the psychiatric assessment or psychiatric follow up appointment.
Q: When a Non-Title XIX/XXI person determined to have SMI with third party coverage goes to the pharmacy to pick up a generic medication that is covered both on the ADHS/DBHS Non-Title XIX Medication Formulary and the third party's formulary, who does the person give his/her co-payment to?
A: If the third party payor's co-payment is greater than $3, the RBHA will cover the co-payment. The person will pay his/her co-payment at the time of his/her physician visit. If the third party payor's co-payment is less than $3, the person will pay his/her co-payment at the pharmacy.
Q: Related to dual (Medicaid/Medicare) eligible persons, the policy says that TXIX/XXI funds cannot be used to pay for cost sharing of Medicare Part D Prescription Drug Coverage. Therefore, are we to use NTXIX funding to pay for the cost sharing for TXIX members? A: According to "ADHS/DBHS Guidelines to RBHAs and Providers for Services to Non-Title XIX Members with Serious Mental Illness" the population served with this appropriation is limited to "Non-TXIX SMI Members." The appropriation shall not be used for co-payments for TXIX members.
Q: Are TXIX members now expected to pay their own cost sharing for Medicare Part D? A: Yes – Federal regulations (the Medicare Modernization Act) do not allow Title XIX/XXI funds to be used for Medicare Part D cost sharing. Non-Title XIX/XXI funding specifically covers services for Non-Title XIX/XXI persons.
Q: Has notice gone to TXIX/XXI eligible persons from AHCCCS about coverage of Medicare Part D cost sharing? A: AHCCCS provided notice to members in February 2009 that Medicare Part D co-payments would no longer be covered. Both AHCCCS and ADHS/DBHS were appropriated limited funds for coverage of Medicare Part D co-payments, and these funds are no longer available. Due to recent budget cuts, ADHS/DBHS is also not able to continue to cover Medicare Part D co-payments for TXIX/XXI eligible persons.
Q: Does the ADHS/DBHS co-payment apply to crisis services?
A: No, currently co-payments are not assessed for crisis services.
Q: Is there a copayment for the RN/LPN services?
A: The ADHS/DBHS co-payment is for the medication only benefit package, which means that the fee for the benefit is associated with all of the services in the benefit, including RN/LPN services. However, the co-payment is only collected at the time of a person's psychiatric assessment or psychiatric follow up visit.
Q: Is there a co-payment for room and board?
A: The ADHS/DBHS Guidelines to RBHAs and Providers for Supported Housing Services states that persons may be charged a fee for the cost of room and board. Providers who charge a fee will have to apply the fee in accordance with a clearly established policy.
Q: Are RBHAs responsible for covering co-payments for Non-Title XIX/XXI persons determined to have SMI who go out of network.
A: It is not expected that Non-Title XIX/XXI persons determined to have SMI will go out of network for services covered in the medication only benefit. However, if a Non-Title XIX/XXI person determined to have SMI chooses to go out of the RBHA network for services, the RBHA is not responsible for covering the services or co-payment for those services provided out of network.
Q: Are providers responsible for covering transportation of Title XIX/XXI persons age 21 and older? A: Passage of HB 2010 requires AHCCCS to eliminate coverage of certain services for adults age 21 and older, effective October 1, 2010. Non-emergency transportation is one of the services identified to no longer be covered. However, AHCCCS must first receive approval from the Centers for Medicaid and Medicare Services (CMS) before coverage of non-emergency transportation is eliminated. Even if CMS approves this change, it is unlikely that it will go into effect on October 1, 2010. Updates can be found on the AHCCCS website at the following location: http://www.azahcccs.gov/reporting/legislation/sessions/2010/BenefitChanges.aspx
Q: Can providers deny a service to a person if it is known that a third party (i.e., other insurer) will provide the service? Can the RBHA deny payment to the provider if the provider is aware that a person has third party coverage?
A: Federal regulations require that providers utilize cost avoidance and post payment recovery when individuals have third party coverage to ensure that Medicaid funds are not inappropriately utilized. As such, providers can deny a service to a person if it is known that the person's third party is responsible for covering the service and the person impedes the provider's ability to bill the third party payor. Additionally, RBHAs can deny payment to the provider if the provider bills the RBHA for services that should have been billed to the third party payor.
With regard to Non-Title XIX/XXI funds, state law requires screening of individuals seeking public behavioral health services for AHCCCS eligibility and enrolling Medicare eligible individuals in Part D to ensure that these funding sources are utilized instead of state-only funds. Individuals who refuse to participate in the screening and enrollment processes are not eligible for public behavioral health services. Providers must bill Medicare or other third party payors prior to utilizing Non-Title XIX/XXI funds for coverage of services.
Frequently Asked Questions for Providers – June 18, 2010
Q: Could students pursuing licensing in mental health care counseling (who require internships), be a resource to get volunteer assistance to help cover shortage in staffing at Behavioral Health Provider sites?
A: Yes, volunteers could provide behavioral health services, but the licensee must comply with all rules for staff members, such as verification of skills and knowledge, clinical supervision, training and orientation. Also, they would be considered BHT's as they are not yet independently licensed.
A: Please submit your billing questions to the OPS Mailbox.
Frequently Asked Questions for Providers – June 4, 2010
Q: How do I assist a Veteran to apply for enrollment with the VA health care system?
A: Veterans can apply for enrollment in the VA health care system by completing VA Form 10-10EZ, Application for Health Benefits. The application form can be obtained by visiting, calling or writing any VA health care facility or Veterans' benefits office. Forms can also be requested toll-free from VA's Health Benefits Service Center at 1-877-222-VETS (8387). Enrollment and eligibility information can be found at http://www4.va.gov/healtheligibility/application/
Q: How can a person verify enrollment with the VA health care system?
A: To verify enrollment, call the VA toll-free at 1-877-222-VETS (8387) to get the facility's telephone number.
For more VA health care-related questions and answers, visit http://www4.va.gov/healtheligibility/library/pubs/healthcareoverview/#EnrollmentFAQs
Q: When will the increased Medicaid eligibility (increased Federal Poverty Level) in the Patient Protection and Affordable Care Act take effect?
A: President Obama signed the Patient Protection and Affordable Care Act (also referred to as federal healthcare reform) into law on March 23, 2010. Federal healthcare reform will require states to increase their Medicaid eligibility to 133 percent of the federal poverty level (Arizona is currently at 100 percent), but that doesn't go into effect until 2014.
Q: What is going to happen to the new referrals that are non-Title 19?
A: Everyone who is non-Title 19 (not enrolled in AHCCCS) will have the same limited services available to them regardless of when they enter the system.
Q: Will inpatient treatment be provided for non-Title 19 individuals?
A: No, inpatient services will no longer be a covered service for non-Title 19 individuals after July 1, 2010. Brief crisis stabilization and other crisis services including mobile crisis and the county crisis hotline will be available for individuals who are non-Title 19 (see /bhs/updates/budgetGuidelines.htm ).
Frequently Asked Questions for Providers – June 2, 2010
Q: Is Antabuse (Disulfiram) a generic medication? (Revised)
No, Antabuse (Disulfiram) is not a generic medication. The Non-Title XIX Medication Formulary has been updated to remove Antabuse and to add Gabapentin. Please see the revised formulary.
Frequently Asked Questions for Providers – May 28, 2010
Q: If a non-TXIX person is receiving supported housing, what is the expectation of these providers after July 1, 2010? Will providers have to continue to provide these services without compensation?
A: No, providers will not be expected to continue services without compensation. The supported housing general fund can continue to be used for compensation. See the Supported Housing Guidance Document
. There is no deadline for transitioning these individuals out of supported housing, although efforts should have begun in May to identify and transition to safe alternative housing or funding sources. These individuals shall not be evicted based solely on their non-TXIX status. The Supported Housing General Fund can be used to continue to support these individuals until they are transitioned to an alternative setting or funding source. For those individuals ready to transition to an alternative setting, it is acceptable to do so before the lease ends provided that the lease has a provision for both parties to mutually rescind the lease under the Arizona Residential Landlord Tenant Act. As long as it is in the best interest of the member, it is the expectation of ADHS/DBHS' that if alternate living settings or funding are available individuals should transfer to that arrangement.
Q: Our providers are concerned that licensing requires more than has been outlined in the reduced benefit package and the related requirements…who trumps? Thanks
A: Please see the "ADHS/DBHS Guidelines to RBHAs and Providers: Documentation Requirements for Services Provided to Non-Title XIX Members with Serious Mental Illness."
Frequently Asked Questions for Providers – May 17, 2010
Q: Can cost of Inpatient psychiatric care or level 2 or 3 to member be used as spend down for eligibility for T19?
A: See the Family Assistance Administration Policy Manual - FAA5.O Medical Expense Deduction (MD) : 05 MD Eligibility Factors : C MD Medical Expenses: .02 MD Allowab
Q: Title 36 - Are the counties responsible to pay for COE & COT?
A: It is not clear if the statutes create an obligation for a county to pay for inpatient treatment services or COT. Payment for pre-petition screening and COE services are clearly a county responsibility and the statutes make reference to that in a number of places. When it comes to COT and voluntary treatment, the statutes say the person shall be charged unless the person is indigent, and in that instance, the person is not obligated to pay. While it is clear that an indigent person is not required to pay for COT, the state statute is silent on who is required to pay for the COT when a person is indigent.
Q: On the Crisis sheet, under benefit administration, #5 states that RBHA's shall use SAPT funding for the provision of substance abuse crisis services/detoxification services. Does this mean that the SAPT funding for FY11 will be utilized exclusively for those areas? Do you anticipate there will be SAPT funding for the GMH/SA population for treatment and/or supportive housing services?
A: Only a portion of SAPT funding will be used to support crisis/detoxification services; not all SAPT dollars will be allocated this way. There will be SAPT dollars available for other, non-crisis services.
Q: On the Housing sheet, under Population Served, #1 states that the RBHA's shall use the Supported Housing – General Fund to prioritize serving individuals with SMI who are TXIX. Do you anticipate that there will be any supportive housing funding available for the TXIX GMH/SA population?
A: No. ADHS/DBHS does not anticipate utilizing any supported housing funds for the GMH/SA population. The RBHAs are asked to "prioritize" individuals with SMI who are TXIX because ADHS/DBHS will continue to use some funds for the NTXIX population currently residing in state funded housing. However, moving forward, supported housing funds will be used for TXIX-SMI current and new members only.
Q: How can we collectively utilize the medication resources available through pharmaceutical companies that offer assistance programs? Can we develop a statewide resource for tapping this resource? Could we use savings here to provide transportation, case management or housing?
A: A "Tips" document is being developed to assist with the use of Pharmacy Assistance Programs, but it appears they may not be available for many medications since individuals do have some type of pharmacy benefit, albeit limited. A statewide program would be ideal, but these do not currently exist. We will be tracking expenditures closely throughout the year, but do not anticipate excess funds that could support transportation or other benefits.
Q: If a non-TXIX person is receiving residential services (Level I, II, III), what is the expectations of these providers after July 1, 2010? Will providers have to continue to provide these services without compensation?
A: Level I, II, and III services are not covered benefits. From now until July 1, during the transition of non-TXIX SMI members to the new benefit package, providers should explore alternative payment options. After July 1, 2010, unless there is other TPL coverage, the individual is responsible for the cost of the services and the providers can bill the individual for these costs. See above question regarding factoring in the cost of inpatient psychiatric care as a spend down for eligibility for T19.
Q: When the funding for non-TXIX individuals is exhausted, what is the expectation of providers?
A: ADHS/DBHS will work with the RBHAs and providers to carefully track expenditures. ADHS/DBHS may explore making adjustments to enrollment or the benefits in order to keep available funding throughout the fiscal year.
Q: In rural areas, transportation is a significant problem and may prevent some non-TXIX SMI members from being able to access the medication benefit. There is no public transportation. What are our options?
A: ADHS/DBHS encourages you to work closely with your RBHA and investigate any other community services that may be available. Options should be addressed on an individual level as well, in terms of looking for family members, neighbors, co-workers, etc.