Medicaid Mental Health Services for People
With Developmental Disabilities
With Developmental Disabilities
Criteria for Behavioral Health Organizations (BHOs) and Community Mental Health Centers in the assessment of Mental Health Conditions for Individuals with Developmental Disabilities.
Official Link:
http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1212398231002
COLORADO DEPARTMENT OF HEALTH CARE POLICY & FINANCING
1570 Grant Street, Denver, CO 80203-1818 (303) 866-2993 (303) 866-4411 Fax (303) 866-3883
John W. Hickenlooper, Governor Sue E. Birch, MBA, BSN, RN, Executive Director
September 19, 2011
Dear Stakeholders:
Attached please find the written criteria currently approved by the Department of Health Care Policy and Financing for use by Behavioral Health Organizations (BHOs) and their providers in the assessment and treatment of mental health conditions for individuals with developmental disabilities. This document is the result of eighteen months of collaborative work between the BHOs, Community Centered Board (CCB) representatives, Developmental Disabilities (DD) advocates and the Department. These criteria are considered to be a starting point to address longstanding uncertainty about treatment protocols and service coordination between the CCB and Mental Health systems in Colorado. Comments, concerns and suggestions about these criteria received from CCB representatives, DD and mental health advocates, persons with DD and many other groups and individuals contributed significantly to the development of these criteria.
These guidelines have been approved by the Department and are included by reference in the FY10 BHO contracts.
The Behavioral Health Organizations have requested any staff, consumers or advocates who encounter any difficulties accessing the mental health system in accordance with these guidelines, to please contact the Executive Director of the appropriate BHO, as follows:
• Denver, Access Behavioral Care: Robert Bremer (720) 744-5240
• Adams and Arapahoe Counties, Behavioral Healthcare, Inc: Roger Gunter (720) 490-4399
• Boulder, Broomfield, Clear Creek, Gilpin and Jefferson County, Foothills Behavioral Health Partners: Tom Clay (303) 432-5953
• Fort Collins, Greeley and northeast Colorado: Northeast Behavioral Health Partnership, Karen Thompson: (970) 347-2372
• Colorado Springs, Pueblo, southern Colorado and western slope: Colorado Health Networks: Arnold Salazar (719) 587-0899
The Department looks forward to receiving ongoing stakeholder feedback about the efficacy of these guidelines and working with stakeholders to continually improve service delivery for this vulnerable population.
BHO Practice Standards: Evaluation and Treatment of Covered Mental Illness (MI) in Children, Youth, and Adults with Developmental Disability (DD)
Providing services to individuals with both a mental illness and a developmental disability is a complicated challenge to the provider community in meeting a DD/MI individual’s behavioral health needs. Co-occurring mental health disorders and developmental disabilities are relatively common. People with developmental disabilities should be afforded the same access to mental health services as the general population. The intent of this document is to ensure that the presence of a diagnosis of developmental disability does not decrease the diagnostic significance of any accompanying mental illness. A misdiagnosis could result in the use of inappropriate or ineffective interventions.
Although behavioral problems are not universal among the DD population, many individuals with a
developmental disability do show problems with impulse control, self-management of their behavior, and may have problems with mood swings, which may or may not be part of their developmental delay. The high rate of co-occurring neurological and general medical conditions can further complicate the diagnostic profile for these individuals.
The distinction between emotional and behavioral symptoms deriving from an individual’s
developmental disability, organic brain pathology, and/or mental illness covered under the Colorado Medicaid Community Mental Health Services Program is frequently difficult, and at times controversial and contentious. For this reason, it is inherently difficult to sort out treatment and payment responsibilities in these situations, as these criteria attempt to do.
This document has been developed by the Behavioral Health Organizations (BHOs) in collaboration with Community Center Boards (CCBs), developmental disability professionals, consumer advocates and other key stakeholders, in the interest of fulfilling their responsibilities under the Colorado Medicaid Community Mental Health Services Program, and to meet the BHO/HCPF contract requirement, which states, “The Contractor [BHO] shall develop written criteria for determining whether the need for mental health services for a Medicaid recipient with co-occurring mental illness and developmental Disabilities is a result of the individual’s mental illness, or a result of the individual’s developmental Disability…The criteria shall be approved by the Department.” The document is an attempt to define these criteria for use by evaluating clinicians. It is not intended to fully describe the collaboration between providers, BHOs and CCBs, that is both required and embraced as values (and in most cases as a reality) by those organizations, by families, and by advocates for individuals with DD/MI. The Colorado BHOs have adopted the following Practice Standards for their Medicaid recipients with a developmental disability:
1. In no circumstance, does the presence of DD preclude an assessment for co-occurring mental illness covered under the Colorado Medicaid Community Mental Health Services Program. BHOs and their contracted providers will not deny services for a covered diagnosis on the basis of that covered diagnosis not being primary. The presence of a covered diagnosis and the BHO’s determination that the issues requiring treatment are related to that covered diagnosis shall be the basis for authorizing appropriate, covered services.
2. A BHO provider will complete a face-to-face assessment on any child, youth, or adult with DD who is referred for evaluation for covered mental illness according to that BHO’s regular intake and admission procedures and standards. The BHO will provide a mental health assessment for
any child, youth or adult with a developmental disability who is referred for evaluation of a covered mental illness. For consumers whose developmental disability and/or level of functioning precludes the use of standard evaluation protocols, the BHO will solicit the participation and/or assistance from someone, such as the CCB case manager, or family member, who can provide information needed to conduct the assessment. Evaluations will be conducted in a secure setting to ensure the safety of a consumer who is behaviorally out of control.
3. The BHO will complete a new face-to-face assessment on any re-referred consumer in which its last assessment is greater than 120 days old.
4. In the specific circumstance in which a BHO provider has assessed a consumer with DD within the past 120 days and services have been denied, and the consumer is re-referred for another assessment within that 120-day window, the BHO will re-assess whether there has either been a change in the consumer’s mental status or if new and relevant information have been provided.
5. Referral for evaluation of Medicaid recipients with DD can be made 24 hours a day, 7 days a
week through the BHO’s regular access telephone numbers.
6. Routine and urgent referrals are evaluated within the network resources of the BHO. Emergency referrals may be evaluated either within a BHO network site or by BHO staff in a hospital Emergency Department or other safe environment. After-hours emergency referrals are evaluated in a safe environment, usually in a hospital Emergency Department.
7. All evaluations during regular working hours are reviewed by an experienced licensed professional within the BHO provider network if there are diagnostic uncertainties. Any decision to deny services to a consumer with a developmental disability will be reviewed by the BHO Medical Director or physician designee. All after-hours evaluations are reviewed with the on-call psychiatrist prior to a denial being issued. In all BHOs, an initial appeal of any decision to deny a request for services requires that the denial be reviewed by another psychiatrist other than the psychiatrist who issued the first denial.
8. BHOs may also utilize courtesy evaluations from other BHOs, and/or delegate emergency assessment to hospital emergency department personnel for Medicaid recipients requiring assessment outside their network areas. If treatment is medically necessary (as defined in item #9 below) outside the network area, the BHO will negotiate a single-case agreement or other non-network arrangement with a qualified provider to deliver that medically necessary clinical care.
9. All treatment decisions are based upon the presence of covered mental illness as defined under the Colorado Medicaid Community Mental Health Services Program; and, evidence that the referring symptoms are associated with that covered mental illness, that treatment of the symptoms is medically necessary, and that it is provided within the least restrictive environment. The HCPF document, labeled “Exhibit D1 Covered Mental Health Diagnoses” from the FY10 BHO contract accompanies this document and is available from HCPF or any BHO.
10. Services may be authorized either in whole or in part based upon the relative contribution of covered and non-covered (DD and/or organic brain pathology) conditions, and any collaborative arrangements in place between the BHO and the CCB involved with the individual.
11. At the time of evaluation, the BHO will review all relevant and available information including records of past diagnoses and treatments; however, the BHO will evaluate the provider’s diagnostic formulation based on the preponderance of the medical evidence available at the time. If there is not adequate evidence available upon which to accept or challenge the diagnostic formulation of the provider, the BHO may defer its final authorization decision until sufficient information has been received. Such a decision to pend or delay authorization does not itself infer a delay in the initiation of treatment. Treatment may be initiated as part of an extended evaluation process, but this does not presume a covered diagnosis or continued service authorization beyond this evaluation period.
12. Cases in which the BHO evaluator disagrees with previously assigned “by history” diagnoses will be reviewed and approved by the Medical Director or physician designee before any denial is issued.
13. If the physician determines that requested services are not medically necessary, the consumer, family member, CCB Case Manager and/or authorized representative will be given detailed written information, in accordance with HIPAA regulations, about the clinical rationale for the denial as well as information about all available appeal rights and assistance with filing an appeal through the BHO.
14. The BHOs acknowledge that diagnosis often “evolves” over a period of time as the natural progression of a disorder further defines itself ; and, as new, better, or more complete clinical data is received and integrated into a comprehensive diagnostic formulation. In all situations in which the provider changes a previous diagnostic formulation, they will clearly document both the clinical evidence and rationale for so doing, and the clinical support for the new diagnosis. In addition, the BHO Medical Director will review all changes in diagnosis that result in a denial of services before they take effect.
Guiding Principles for Diagnostic Formulation:
1. The basis for determining the presence of a behavioral health diagnosis covered by the BHO contract is the DSM-IV criteria for that diagnosis. BHOs follow conventional diagnostic practice in considering whether DSM-IV criteria are met, and consider that DSM-IV symptomatology may present atypically in individuals with a developmental disability. However, a DSM-IV diagnosis cannot be made in the absence of reasonably meeting such criteria in the context of an atypical presentation. Diagnostic evaluations will include a review of prior treatment and evaluations, past and current response to prescribed medications, and past and current behavioral presentation as described by care providers, family members and other information sources.
2. Other diagnoses, including the developmental disability, must be present to explain variances from DSM-IV criteria.
3. Consideration is given to the consumer's abilities or disabilities in how DSM-IV criteria present themselves. The diagnostic process must be developmentally sensitive.
4. Additional diagnoses will not be considered in authorizing services when other known and clearly documented diagnoses sufficiently explain the clinical presentation of the consumer.
5. When a specific diagnosis cannot be clearly established (e.g., early in the course of an evolving disorder), the diagnosis with the best prognosis, and that best explains the clinical presentation of the consumer, is assumed over those with poorer prognoses until there is sufficient evidence to clearly document the poorer prognosis conditions. This conservative practice in making a diagnosis is standard in medicine and presumes the individual has the strength and resources to overcome or optimally recover from their disability.
6. Diagnostic services, like treatment services, are driven by the best interests of the consumer, and are provided in the least restrictive setting where services can safely be provided.
7. BHO Medicaid recipients with developmental disability have access to the full spectrum of appeal rights under the Colorado Medicaid Community Mental Health Services Program for adverse decisions rendered with regard to clinical services for the treatment of covered mental illnesses.
8. These guidelines will be reviewed no less than annually and revised if necessary.
Official Link:
http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1212398231002
COLORADO DEPARTMENT OF HEALTH CARE POLICY & FINANCING
1570 Grant Street, Denver, CO 80203-1818 (303) 866-2993 (303) 866-4411 Fax (303) 866-3883
John W. Hickenlooper, Governor Sue E. Birch, MBA, BSN, RN, Executive Director
September 19, 2011
Dear Stakeholders:
Attached please find the written criteria currently approved by the Department of Health Care Policy and Financing for use by Behavioral Health Organizations (BHOs) and their providers in the assessment and treatment of mental health conditions for individuals with developmental disabilities. This document is the result of eighteen months of collaborative work between the BHOs, Community Centered Board (CCB) representatives, Developmental Disabilities (DD) advocates and the Department. These criteria are considered to be a starting point to address longstanding uncertainty about treatment protocols and service coordination between the CCB and Mental Health systems in Colorado. Comments, concerns and suggestions about these criteria received from CCB representatives, DD and mental health advocates, persons with DD and many other groups and individuals contributed significantly to the development of these criteria.
These guidelines have been approved by the Department and are included by reference in the FY10 BHO contracts.
The Behavioral Health Organizations have requested any staff, consumers or advocates who encounter any difficulties accessing the mental health system in accordance with these guidelines, to please contact the Executive Director of the appropriate BHO, as follows:
• Denver, Access Behavioral Care: Robert Bremer (720) 744-5240
• Adams and Arapahoe Counties, Behavioral Healthcare, Inc: Roger Gunter (720) 490-4399
• Boulder, Broomfield, Clear Creek, Gilpin and Jefferson County, Foothills Behavioral Health Partners: Tom Clay (303) 432-5953
• Fort Collins, Greeley and northeast Colorado: Northeast Behavioral Health Partnership, Karen Thompson: (970) 347-2372
• Colorado Springs, Pueblo, southern Colorado and western slope: Colorado Health Networks: Arnold Salazar (719) 587-0899
The Department looks forward to receiving ongoing stakeholder feedback about the efficacy of these guidelines and working with stakeholders to continually improve service delivery for this vulnerable population.
BHO Practice Standards: Evaluation and Treatment of Covered Mental Illness (MI) in Children, Youth, and Adults with Developmental Disability (DD)
Providing services to individuals with both a mental illness and a developmental disability is a complicated challenge to the provider community in meeting a DD/MI individual’s behavioral health needs. Co-occurring mental health disorders and developmental disabilities are relatively common. People with developmental disabilities should be afforded the same access to mental health services as the general population. The intent of this document is to ensure that the presence of a diagnosis of developmental disability does not decrease the diagnostic significance of any accompanying mental illness. A misdiagnosis could result in the use of inappropriate or ineffective interventions.
Although behavioral problems are not universal among the DD population, many individuals with a
developmental disability do show problems with impulse control, self-management of their behavior, and may have problems with mood swings, which may or may not be part of their developmental delay. The high rate of co-occurring neurological and general medical conditions can further complicate the diagnostic profile for these individuals.
The distinction between emotional and behavioral symptoms deriving from an individual’s
developmental disability, organic brain pathology, and/or mental illness covered under the Colorado Medicaid Community Mental Health Services Program is frequently difficult, and at times controversial and contentious. For this reason, it is inherently difficult to sort out treatment and payment responsibilities in these situations, as these criteria attempt to do.
This document has been developed by the Behavioral Health Organizations (BHOs) in collaboration with Community Center Boards (CCBs), developmental disability professionals, consumer advocates and other key stakeholders, in the interest of fulfilling their responsibilities under the Colorado Medicaid Community Mental Health Services Program, and to meet the BHO/HCPF contract requirement, which states, “The Contractor [BHO] shall develop written criteria for determining whether the need for mental health services for a Medicaid recipient with co-occurring mental illness and developmental Disabilities is a result of the individual’s mental illness, or a result of the individual’s developmental Disability…The criteria shall be approved by the Department.” The document is an attempt to define these criteria for use by evaluating clinicians. It is not intended to fully describe the collaboration between providers, BHOs and CCBs, that is both required and embraced as values (and in most cases as a reality) by those organizations, by families, and by advocates for individuals with DD/MI. The Colorado BHOs have adopted the following Practice Standards for their Medicaid recipients with a developmental disability:
1. In no circumstance, does the presence of DD preclude an assessment for co-occurring mental illness covered under the Colorado Medicaid Community Mental Health Services Program. BHOs and their contracted providers will not deny services for a covered diagnosis on the basis of that covered diagnosis not being primary. The presence of a covered diagnosis and the BHO’s determination that the issues requiring treatment are related to that covered diagnosis shall be the basis for authorizing appropriate, covered services.
2. A BHO provider will complete a face-to-face assessment on any child, youth, or adult with DD who is referred for evaluation for covered mental illness according to that BHO’s regular intake and admission procedures and standards. The BHO will provide a mental health assessment for
any child, youth or adult with a developmental disability who is referred for evaluation of a covered mental illness. For consumers whose developmental disability and/or level of functioning precludes the use of standard evaluation protocols, the BHO will solicit the participation and/or assistance from someone, such as the CCB case manager, or family member, who can provide information needed to conduct the assessment. Evaluations will be conducted in a secure setting to ensure the safety of a consumer who is behaviorally out of control.
3. The BHO will complete a new face-to-face assessment on any re-referred consumer in which its last assessment is greater than 120 days old.
4. In the specific circumstance in which a BHO provider has assessed a consumer with DD within the past 120 days and services have been denied, and the consumer is re-referred for another assessment within that 120-day window, the BHO will re-assess whether there has either been a change in the consumer’s mental status or if new and relevant information have been provided.
5. Referral for evaluation of Medicaid recipients with DD can be made 24 hours a day, 7 days a
week through the BHO’s regular access telephone numbers.
6. Routine and urgent referrals are evaluated within the network resources of the BHO. Emergency referrals may be evaluated either within a BHO network site or by BHO staff in a hospital Emergency Department or other safe environment. After-hours emergency referrals are evaluated in a safe environment, usually in a hospital Emergency Department.
7. All evaluations during regular working hours are reviewed by an experienced licensed professional within the BHO provider network if there are diagnostic uncertainties. Any decision to deny services to a consumer with a developmental disability will be reviewed by the BHO Medical Director or physician designee. All after-hours evaluations are reviewed with the on-call psychiatrist prior to a denial being issued. In all BHOs, an initial appeal of any decision to deny a request for services requires that the denial be reviewed by another psychiatrist other than the psychiatrist who issued the first denial.
8. BHOs may also utilize courtesy evaluations from other BHOs, and/or delegate emergency assessment to hospital emergency department personnel for Medicaid recipients requiring assessment outside their network areas. If treatment is medically necessary (as defined in item #9 below) outside the network area, the BHO will negotiate a single-case agreement or other non-network arrangement with a qualified provider to deliver that medically necessary clinical care.
9. All treatment decisions are based upon the presence of covered mental illness as defined under the Colorado Medicaid Community Mental Health Services Program; and, evidence that the referring symptoms are associated with that covered mental illness, that treatment of the symptoms is medically necessary, and that it is provided within the least restrictive environment. The HCPF document, labeled “Exhibit D1 Covered Mental Health Diagnoses” from the FY10 BHO contract accompanies this document and is available from HCPF or any BHO.
10. Services may be authorized either in whole or in part based upon the relative contribution of covered and non-covered (DD and/or organic brain pathology) conditions, and any collaborative arrangements in place between the BHO and the CCB involved with the individual.
11. At the time of evaluation, the BHO will review all relevant and available information including records of past diagnoses and treatments; however, the BHO will evaluate the provider’s diagnostic formulation based on the preponderance of the medical evidence available at the time. If there is not adequate evidence available upon which to accept or challenge the diagnostic formulation of the provider, the BHO may defer its final authorization decision until sufficient information has been received. Such a decision to pend or delay authorization does not itself infer a delay in the initiation of treatment. Treatment may be initiated as part of an extended evaluation process, but this does not presume a covered diagnosis or continued service authorization beyond this evaluation period.
12. Cases in which the BHO evaluator disagrees with previously assigned “by history” diagnoses will be reviewed and approved by the Medical Director or physician designee before any denial is issued.
13. If the physician determines that requested services are not medically necessary, the consumer, family member, CCB Case Manager and/or authorized representative will be given detailed written information, in accordance with HIPAA regulations, about the clinical rationale for the denial as well as information about all available appeal rights and assistance with filing an appeal through the BHO.
14. The BHOs acknowledge that diagnosis often “evolves” over a period of time as the natural progression of a disorder further defines itself ; and, as new, better, or more complete clinical data is received and integrated into a comprehensive diagnostic formulation. In all situations in which the provider changes a previous diagnostic formulation, they will clearly document both the clinical evidence and rationale for so doing, and the clinical support for the new diagnosis. In addition, the BHO Medical Director will review all changes in diagnosis that result in a denial of services before they take effect.
Guiding Principles for Diagnostic Formulation:
1. The basis for determining the presence of a behavioral health diagnosis covered by the BHO contract is the DSM-IV criteria for that diagnosis. BHOs follow conventional diagnostic practice in considering whether DSM-IV criteria are met, and consider that DSM-IV symptomatology may present atypically in individuals with a developmental disability. However, a DSM-IV diagnosis cannot be made in the absence of reasonably meeting such criteria in the context of an atypical presentation. Diagnostic evaluations will include a review of prior treatment and evaluations, past and current response to prescribed medications, and past and current behavioral presentation as described by care providers, family members and other information sources.
2. Other diagnoses, including the developmental disability, must be present to explain variances from DSM-IV criteria.
3. Consideration is given to the consumer's abilities or disabilities in how DSM-IV criteria present themselves. The diagnostic process must be developmentally sensitive.
4. Additional diagnoses will not be considered in authorizing services when other known and clearly documented diagnoses sufficiently explain the clinical presentation of the consumer.
5. When a specific diagnosis cannot be clearly established (e.g., early in the course of an evolving disorder), the diagnosis with the best prognosis, and that best explains the clinical presentation of the consumer, is assumed over those with poorer prognoses until there is sufficient evidence to clearly document the poorer prognosis conditions. This conservative practice in making a diagnosis is standard in medicine and presumes the individual has the strength and resources to overcome or optimally recover from their disability.
6. Diagnostic services, like treatment services, are driven by the best interests of the consumer, and are provided in the least restrictive setting where services can safely be provided.
7. BHO Medicaid recipients with developmental disability have access to the full spectrum of appeal rights under the Colorado Medicaid Community Mental Health Services Program for adverse decisions rendered with regard to clinical services for the treatment of covered mental illnesses.
8. These guidelines will be reviewed no less than annually and revised if necessary.
See Also:
Attorney & teacher Steve Harvey's excellent report on the gap in access to mental
health services confronting children on Medicaid with multiple diagnoses, including a
combination of mental health diagnoses and developmental disabilities, or other
behaviorally relevant diagnoses classified as "medical" rather than "behavioral" by
Colorado Medicaid.
Attorney & teacher Steve Harvey's excellent report on the gap in access to mental
health services confronting children on Medicaid with multiple diagnoses, including a
combination of mental health diagnoses and developmental disabilities, or other
behaviorally relevant diagnoses classified as "medical" rather than "behavioral" by
Colorado Medicaid.