Section
3.13 Covered 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 services
assist and encourage each person to achieve and maintain the highest
possible level of health and self-sufficiency. The provision of
covered services is contingent on each person’s current eligibility
status and, for some persons, may be based on available funding.
Effective January 1, 2006, 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.
3.13.2
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.
3.13.5
Objectives
The intent of this section is as follows:
- Behavioral
health providers must provide medically necessary covered 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 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, illustrates
the available covered services for each population of T/RBHA enrolled
persons. These services must be provided by AHCCCS registered providers
or ADHS-only providers.
This matrix
is a highly condensed summary of available services and their general
reimbursability. It is recommended that behavioral health providers
reference the ADHS/DBHS
Covered Behavioral Health Services Guide. This Guide
also includes other matrices as appendices, which provide other
types of useful 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 dually eligible for 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.
Non-Title XIX/XXI eligible persons
may have coverage of excluded Part D drugs, as well as drugs that
are not included on the PDP or MA plans’ formulary, with Non-Title
XIX/XXI funds in accordance with
PM 3.21, Service
Prioritization for Non-Title XIX/XXI Funding.
3.13.7-C.
Flex Funds
T/RBHAs and/or their subcontracted providers may provide flex funds
up to or exceeding $1,525 per individual per year, 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); or
- 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.
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 offices within ADHS/DBHS for approval:
- For flex
fund requests involving enrolled children, contact the Bureau
of Children’s Services.
- For flex
fund requests involving enrolled adults, contact the Bureau of
Adult Services.
- For flex
fund requests involving substance abuse services, contact the
Bureau of Substance Abuse Treatment and Prevention.
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3.13
Covered Services
Last Revised: 11/08/2005
Effective Date: 03/15/2006 |
