DMH System Restructuring Initiative
Access and Eligibility Workgroup Meeting Minutes
October 4, 2006
Present: Sandy Lewis (Chair), Tim Sheehan, Mary Smith, Brittan Harris, Gustavo Espinosa, Tony Kopera, Donna Buss, Londa Matlick, Dan Kill, Kenzy Vandebrock, Judy Statsinger, Linda Denson, and Sarnia Cotton
- Minutes of the September 15, 2006 Access and Eligibility Workgroup Meeting,
- Eligibility/Levels of Care Grid, and
- Access Standards of Care and Indicators Matrix
Mary Smith convened the meeting at 10:20 A.M. Two guests from the Office of Health Care Access in Chicago accompanying Linda Denson were welcomed and given an overview of the purpose of the workgroup, the two sub-workgroups -- Standards of Care, and Eligibility, and the work products developed by each. It was explained that work products developed by the A&E Workgroup are sent to the SRI Taskgroup as a recommendation. Upon approval by the SRI Taskgroup, the information is sent to the DMH for consideration re: incorporation into fee-for-service system planning. K. Vandebrock questioned if the fee-for-services issues discussed at the A&E workgroup meetings included fee-for-services and services provided by other DHS Divisions, e.g., Rehabilitation, and Substance Abuse. M. Smith clarified that the meetings were limited to DMH's system restructuring initiative.
Access and Eligibility Sub-Workgroup Reports
Tim Sheehan, chair, reported on the work of the Eligibility Sub-workgroup. A Levels of Care (grid) matrix detailing who is eligible for what services has been developed to summarize the work of the committee thus far. The grid was reviewed and modified incorporating recommendations of the workgroup. T. Sheehan suggested that the services outlined in the grid crosswalk to Rule 132, services. It was agreed that this information would be added to the document at a later date.
The grid identifies four levels of care and for each level specifies covered services, eligible populations, eligibility criteria, need for prior authorization for services, recommended benefit level, financial eligibility and service codes (to be added). The workgroup reviewed and discussed the grid by each level.
Level I Issues:
- Harris questioned if linkage case management covered inpatient and/or community services. S. Lewis clarified that all linkage types of services would be included as case management. L. Denson recommended clarifying the language to assure clarity as to which services are included. S. Lewis replied that having the billing codes contained in the grid would assure clarity.
- A question was raised regarding the eligibility criteria and eligible populations for crisis assessment. M. Smith explained that the committee has focused on access to services regardless of payment source noting that services would be accessible to both individuals receiving Medicaid and those who are non-Medicaid. There was further discussion regarding the need to "open" cases for which reimbursement is sought. The need for a capacity grant to cover services such as crisis assessment was also discussed. It was also noted that mental health services for Medicaid and non-medicaid recipients must be the same per F. Kopel, Family Healthcare Services (HFS). DMH's reimbursement process must agree with the Medicaid policy so that the billing for Medicaid and non-Medicaid will be compatible. The Coordination of Benefits Workgroup will address this issue. Other financial issues were discussed, but tabled since the focus of the Access and Eligibility workgroup is to make recommendations regarding access to services and not the payment process. S. Lewis volunteered to compile guidelines explaining various "assumptions", which would be added to the Level of Care grid (a.k.a., the assumption page).
Level II Issues:
- Does level II cover services received by families of children with SED. S. Lewis responded by noting that billing for family services could still be submitted as Family Therapy, and the medical necessity for this service would be identified in the treatment plan.
- D. Kill asked if the new definition for community support services includes admission criteria. Sandy verified that currently it does not.
- There was discussion by the group regarding the differences between community support individual and community support group.
- Level II eligible population criteria was modified to include the target and eligible population.
- K. Vandebrock questioned the reason for using SED criteria for individuals 18 to 22. S. Lewis replied that the purpose was to ensure continuity of services for youth in transition from the child service system to the adults service system.
- D. Kill recommended clarifying "30 visits", suggesting 30 units of service or episodes
Level III Issue discussion included the following:
- Why community support - group and individual were in level 2 and community support - team is included in Level III
- Whether community support team is a step-down from ACT services.
S. Lewis explained that community support team was a step-down from ACT services and that the definition of the service community support is new with differing levels of care. S. Lewis and L. Denson noted that in FY 08, more pre-authorizations for services may be required.
Level IV services were reviewed with the following discussion:
- L. Denson questioned why PSR was at Level IV as opposed to Level III.
- D. Kill questioned if recovery principles should be included in Levels III and IV, as they relate to treatment and recovery guidelines. It was suggested that the following statement be added: Service level is dependent upon Medical Necessity and Recovery Guidelines
- Poverty level guidelines were discussed, but no modifications were recommended.
It was suggested that a list of assumptions and other issues to be considered with regard to eligibility for services and level of care be documented and attached to the eligibility/level of care matrix.
Standards of Care
Gustavo Espinosa, chair, provided an overview of the work activities of the Standards of Care Sub-workgroup. He explained that the group had reviewed many other sources of standards from across the nation and had developed the Standards of Care matrix with proposed access to care standards and performance indicators. It was also noted that the draft matrix has been reviewed by the Advocates for Cultural Competency to gather feedback regarding the adequacy of the cultural competence standards and indicators. The workgroup was specifically asked for recommendations on prioritizing the standards as a means of reducing the total number of standards and indicators to be recommended.
The workgroup made modifications to the Standards of Care matrix based on the discussion. A follow-up meeting for the sub-workgroup was scheduled for October 10th, at 10:00A.M.to finalize recommended changes for the standards of care matrix.
Next Access and Eligibility Meetings- November 10th, at 10:00 A.M. to Noon. Workgroup members were also asked to hold the date of December 15th.
The Eligibility/Level of Care Matrix and the Access Standards of Care Matrix and Indicators were e-mailed to the entire Access and Eligibility workgroup for review and recommendations on October 11th with a response due back by close of business October 13th. The attached matrices are the most up-to-date versions based on this mailing.
Meeting was adjourned, Submitted by: Sarnia Cotton