DMH System Restructuring Initiative
Access and Eligibility Workgroup Meeting Minutes
August 11, 2006

Materials distributed: Agenda, Minutes from the June 16, 2006 Meeting, Coordination of Benefits issues summary (from Randy Pletcher), Eligibility Research Summary (from Parker Dennison), Role of a Mental Health Recovery Specialist, Recovery Specialist Referral Process.

Present: Sandy Lewis (Chair), Mary Smith, Randy Pletcher, Dan Boehmer, Linda Denson, Brittan Harris, Mark Klocek, Pat Scruton, Gustavo Espinosa, Donna Buss, Londa Mattick, Dan Kill, Sarnia Cotton.

Welcome

At a previous meeting, several members noted that consumer representation on the group had fallen off. The Workgroup has successfully recruited several new members who were welcomed and thanked for participating in the workgroup. The group also welcomed guest Linda Denson, Co-Chair of the SRI Committee, who reinforced the importance of the Access and Eligibility Committee and thanked members for their service and input. Randy Pletcher was also welcomed by workgroup members who expressed a desire to continue interfacing with the Financial Workgroup around issues that relate to access and finance.

Tracking Workgroup Recommendations

There was some discussion regarding what happens to Access and Eligibility (A & E) Workgroup recommendations to the SRI. Sandy Lewis summarized the process as follows:

  1. The minutes of the Workgroup are distributed at every SRI meeting and posted on the DMH website under SRI activities by Fiscal Year.
  2. Sandy provides an oral report at SRI meetings reinforcing the specific recommendations contained in the minutes. SRI members then have the opportunity to request clarification, reinforce recommendations or request additional information. Because the SRI committee is advisory to the DMH, there is not a formal process where each recommendation is voted up or down, but rather all recommendations are passed on to DMH staff for their consideration.
  3. Each quarter in FY06, DMH prepares a status report on the progress of specified goals. The work / recommendations of Access and Eligibility is updated and reported as well. The quarterly Commitment Reports can be viewed on the DMH website (http://www.dhs.state.il.us/mhdd/mh/sri/).
  4. The A & E Workgroup have made the recommendation to the SRI Committee that they begin to list the specific recommendations made to SRI by all Workgroups and by SRI members with a status notation. It was agreed that this is an appropriate and helpful request, however, the task has not been assigned as of yet to any particular individual to implement.

Coordination of Benefits

Randy Pletcher attended the meeting to discuss issues and implications of Coordination of Benefits as it relates to the interaction between access to care and finance. Although the Financial Workgroup has started working on this issue, the importance of the Access and Eligibility Workgroup's input into this process was stressed. Randy discussed three basic benefit status types of individuals seeking services supported by DMH dollars:

1) Consumers with Medicaid benefits

2) Consumers without Medicaid benefits with either private funds or insurance

3) Consumers without Medicaid or other benefits (likely "indigent" status)

DMH wants to ensure that agencies are maximizing their funding options by billing for private funds and insurance in addition to DMH funding. There is an expectation that insurance companies should be paying their fair share for services rendered. However, as these consumers could potentially bring in the most funding to providers if the DMH pays the full rate in addition to full reimbursement from private funds/insurance, serving them may be viewed as significantly more lucrative than serving consumers with other sources of payment. The DMH does not want to inadvertently incent the provision of services to consumers with private pay/insurance payment sources over other consumers seeking services through the publicly funded mental health system.

Mary Smith noted the important of addressing clinical need regardless of payment source. There is a need to determine who should receive publicly funded mental health treatment. There is an important interaction between psychiatric disability, clinical need, financial status and service type that should be factored into any decision-making and recommendations. Workgroup members agreed with this premise. The need to perform several analyses to inform recommendations was discussed. There is a need for an analysis of provider billing as it relates to the coordination of benefits factoring in clinical need, however with current reporting practices this is problematic. Randy noted that some providers report "third party liability" payments through RoCS and others do not. If there is a desire to collect the data needed to inform decision-making regarding coordination of benefits, we may have to initiate a special study in which providers report all third party liability payments for informational purposes. Site visits may also inform this data collections and decision-making effort. The Workgroup made the following recommendation with regard to coordination of benefits:

Recommendations

  • The Access and Eligibility Workgroup is concerned about the consequences of coordination of benefits in which prioritization of services to consumers is based solely on benefits. It was recommended that client access and clinical need be factored into to coordination of benefits policy. Recommendations to SRI regarding coordination of benefits should address a combination of financial, access and clinical need issues.
  • The A&E workgroup should have joint meetings with the Financial subgroup that is working on this topic. Recommendations regarding this topic should be joint recommendations from the Finance Committee and Access and Eligibility (to ensure a balance between financial and access concerns).
  • DMH should study the effect of billing as it relates to the coordination of benefits at the provider level taking into account the demographic and clinical characteristics of the three groups listed above by benefits type. The effect of coordination of benefits on homeless and undocumented clients should be studied, as well as the effect of regulatory standards of Medicaid as a payment.
  • DMH should identify areas that would be excluded from the coordination of benefits (fundraising, etc). The distinction could be made between funds covering excess cost or individual services.
  • The Financial Workgroup should investigate the possibility of disproportionate share payments (used by hospitals) to incent providers to service consumers without insurance benefits.

To begin this process, joint meetings should be hosted between Access and Eligibility and Finance as soon as possible. Mary Smith and Sandy will join the Finance Committee's meeting this Monday to discuss the timing and agendas for these meetings. The Finance Committee's goal is to draft specific recommendations on this topic by the end of September, thus joint meetings will have to begin soon.

Parker Dennison (P & D) Eligibility Study

The Committee reviewed and commented on the P&D study of Eligibility conducted across nine states. It was noted that there was limited information regarding the transitioning-out aged youth which was a particular interest of the A & E Eligibility subgroup. Linda Denson noted there was little information on the child and adolescent population. Linda also expressed concern that the focus of many discussions regarding mental health services for youth tends to focus on SASS services which are a small part of the mental health service delivery system for children and adolescents. There were also questions posed regarding the operational definitions used in the P & D study--for example DMHs definition of "History" or "Duration" as an eligibility factor versus the definitions used by other states surveyed by P & D. It was also noted that the tiers of benefits for individuals identified as Non Medicaid was of interest. Mary and Sandy will follow up with Rusty Dennison regarding these questions. They will also work with Rusty to determine a time when he can be available for a teleconference call with the Workgroup. It was recommended that the Eligibility Subcommittee continue to review this document and determine if there are implications for the current recommendations with regard to eligibility standards and definitions.

Standard of Care Subcommittee

It was recommended that the Standards of Care Committee reconvene to continue their work on Standards.

Other Business

Sandy and Mary will complete the FY06 Year End report based on final comments from the Committee and submit this to SRI. There is no need to attach a list of all documents reviewed or distributed to the Committee members in the year-end report since these are documented in the monthly minutes.

Donna Buss and Londa Mattick distributed information regarding the role of Recovery Specialists (agencies use different terms for these roles - Peer Support; Engagement Specialists; PSR Specialists; Prosumers etc.) and the protocol they follow as they provide services in their community.

Next Meeting

It was suggested that the A&E committee meet monthly from noon to 3pm instead of 10 to 1pm. The next meeting is scheduled for September 15th. A call in number can be provided for those who are unable to attend in person. If there are workgroup members that would like to retain the 10-1pm time slot for meetings, Mary and Sandy should be contacted immediately.