Section
3.13 Covered Behavorial Health Services
3.13.1
Introduction
3.13.2 References
3.13.3 Scope
3.13.4 Did you know…?
3.13.5 Objectives
3.13.6 Definitions
3.13.7 Procedures
3.13.7-A: Covered services matrix
3.13.7-B. Medicare Part D Prescription Drug
Coverage
3.13.7-C: Flex Funds
3.13.1
Introduction
The ADHS/DBHS system of care offers an assortment of covered behavioral
health services to meet the individual needs of persons seeking
behavioral health treatment. The continuum of available services
includes supervised and semi-supervised facility-based care, an
array of treatment services and support services. Covered behavioral health services
assist and encourage each person to achieve and maintain the highest
possible level of health and self-sufficiency. The provision of
covered behavioral health services is contingent on each person’s current eligibility
status and, for some persons, may be based on available funding.
3.13.2
References
The following citations can serve as additional resources for this
content area:
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3.13.3
Scope
To whom does this apply?
3.13.4
Did you know?
The ADHS/DBHS Covered Behavioral Health Services Guide contains
information regarding each of the covered services that are available
through the publicly funded behavioral health system including:
- A definition
of each service;
- The requirements
of individuals or agencies providing the service; and
- Any limitations
to using or billing for the service.
Medicare
eligible behavioral health recipients, including persons who are
dually eligible for Medicare (Title XVIII) and Medicaid (Title
XIX/XXI), will receive Medicare Part D prescription drug benefits
through Medicare Prescription Drug Plans (PDPs) or Medicare
Advantage Prescription Drug Plans (MA-PDs). Prescription drug
coverage for Medicare eligible behavioral health recipients enrolled
in Part D will be based on Part D plans’ formularies.
3.13.5
Objectives
The intent of this section is as follows:
- Behavioral
health providers must provide medically necessary covered behavioral health services,
within their scope of practice, based upon the needs of the person.
- Services
must be provided in collaboration with other agencies to coordinate
the culturally appropriate delivery of covered behavioral health
services with other services and supports provided to the person
and the person’s family.
- Covered behavioral health services
must be available to family members of persons enrolled with a
T/RBHA to the extent that services are provided in support of
the treatment goals of the identified eligible or enrolled person.
3.13.6
Definitions
Flex
Funds
Medically
necessary covered services
3.13.7
Procedures
3.13.7-A.
Covered services matrix
PM Attachment 3.13.1, Covered Services Matrix, lists the available covered behavioral
health services for each population of T/RBHA enrolled persons. These services must be
provided by AHCCCS registered providers, ADHS-only providers or Medicare registered
providers.
PM Attachment 3.13.1, Covered Services Matrix is a condensed summary of available
behavioral health services and related funding sources. Behavioral health providers
may reference the ADHS/DBHS Covered Behavioral Health Services Guide for more detailed
information.
3.13.7-B. Medicare Part D Prescription Drug
Coverage
Persons eligible for Medicare Part D must access the Medicare Part D
prescription drug coverage by enrolling with a Medicare Prescription
Drug Plan (PDP) or Medicare Advantage Prescription Drug plan
(MA-PD). Persons eligible for both Medicare Part D and Title
XIX/XXI (AHCCCS) will continue to have coverage of the following
excluded Part D drugs through Title XIX/XXI, if not included in the
PDP or MA plans’ formulary:
- Benzodiazepines;
- Barbiturates; and
- Certain over the counter drugs.
3.13.7-C.
Flex Funds
T/RBHAs and/or their subcontracted providers may provide flex funds, based on available
funding.
When can
flex funds be used?
Flex funds may only be used for goods and/or services that are described
in the person’s service plan that cannot be purchased by any
other funding source. The good and/or service to be provided using
flex funds must be related to one or more of the following outcomes:
- Success
in school, work or other occupation;
- Living at
the person’s own home or with family
- Development
and maintenance of personally satisfying relationships;
- Prevention
or reduction in adverse outcomes, including arrests, delinquency,
victimization and exploitation; and/or
- Becoming
or remaining a stable and productive member of the community.
When can
flex funds not be used?
Flex funds must not be used for:
- Inpatient
or other covered behavioral health services;
- The purchase
or improvement of land;
- The purchase,
construction or permanent improvement of any building or other
facility (with the exception of minor remodeling consistent with
this Section); and
- The purchase
of major medical equipment.
T/RBHAs and/or
their subcontracted providers must use flex funds for the direct
purchase of goods and/or services and may not provide flex funds
as direct cash payments to behavioral health recipients or their
families. See the
ADHS/DBHS Covered Behavioral Health Services
Guide for additional information regarding flex funds and applicable
billing limitations.
How are
flex funds accessed?
Each T/RBHA may approve flex fund services of up to $1,525 per individual/family
per year. Clinical teams may access flex funds by: contacting the
Gila River RBHA Clinical Manager at (602) 528-7136.
Approval of
flex fund expenditures are made by the Gila River RBHA Clinical
Manager based on available funding and the following criteria:
- A determination
that the requested goods and/or services cannot be purchased by
any other funding source; and
- A determination
that the flex fund expenditure is described in the person’s
service plan.
The T/RBHA must
forward requests for approval of flex fund expenditures of $1,525
or more to the following office within ADHS/DBHS for approval:
- Director of Clinical Operations
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3.13
Covered Services
Last Revised: 09/15/2009
Effective Date: 09/15/2009 |
