Proposed MH/SA Access to Care Criteria Sets a Higher Standard

NC DHHS recently posted its latest Medicaid Transformation concept paper focused on the Standard Plan access to care and network adequacy standards. The paper does not outline standards for the Tailored Plan. The difference between the current access to care standards under the Medicaid (b)(c) waiver and the proposed requirements under the Standard Plan are that the proposed access to care standards will require a quicker response by providers in the network.

The concept paper reviews a general outline of expectations for Prepaid Health Plans (PHPs), the plan managers for the Standard Plan which will cover individuals with mild-to-moderate mental health and substance use disorders. PHPs are expected to meet federal and State requirements for offering all services within the Standard Plan, and the document notes benchmarks for offering provider choice, access timeframes, and provider proximity to consumers (provider proximity standards may vary across geographic areas of the State).

As written, provider networks in the Standard Plan will be open to any willing providers from the beginning. Exceptions may occur when a PHP and provider are not able to negotiate a rate or when there are provider quality concerns. PHPs can also enter into out-of-network agreements, single case agreements, and use telemedicine to assure consumers access to appropriate services. Each Medicaid recipient under the Standard Plan will be allowed one mental health assessment and one substance abuse assessment per year without prior authorization. Adults and children with special care needs will have direct access to specialists. PHPs will be monitored to ensure services within their network meet a level of cultural competence. Not only will NC DHHS monitor the PHPs, but an external quality review organization (EQRO) will be retained to evaluate whether PHPs are meeting their contractual obligations for quality services. These network adequacy standards for PHPs are similar to those currently followed under the LME/MCO standards.

NC DHHS is requesting feedback on this concept paper by March 15, 2018, with particular interest in feedback on the behavioral health access to care provisions for the Standard Plan (See Table 5, page 12 of the concept paper). They include four access criteria:

1. Access to community/mobile services for behavioral health care is expected to be available 24 hours a day/7 days a week and the PHP is expected to ensure that the consumer is seen within 30 minutes of the request.
2. Urgent care appointments for behavioral health needs are expected to occur within 24 hours of contact between the consumer and PHP.
3. Routine care appointments for behavioral health needs are expected to occur within 14 days of contact between the consumer and PHP.
4. After-hours access to Behavioral Health Practitioners for emergency or urgent behavioral health needs is expected to be available 24 hours a day/7 days a week and the PHP is expected to ensure the consumer is seen immediately.

In comparison, the current expectation within the Medicaid 1915(b)(c) waiver for access to services is as follows:

1. Emergency Services are expected to be provided face-to-face within 2 hours of the request.
2. Urgent Services are expected to be provided via face-to-face assessment and/or treatment with 48-hours after the consumer has requested the service.
3. Routine Services are expected to be provided within 14 calendar days of the date of request.

Several other concept papers are expected to be published by the Department within the next month on topics such as the Advanced Medical Home and care management, quality management, credentialing, and the role of the Enrollment Broker.