Medicaid Substance Abuse Treatment Spending: Findings Report. Table E.2. Details of Coverage of MH and SA Services in Hmos and Bhos, by State

09/28/2012

TABLE E.2. Details of Coverage of MH and SA Services in HMOs and BHOs, by State

 State Has HMO/HIOState Carves SA Out of HMOs/HIOsState Includes SA Services in HMOs/HIOsNotes on Managed Care Coverage of SA ServicesSource of Managed Care Coverage InformationKnown Data Quality Issues
Alabama (AL)XX Alabama has a maternity care Prepaid Inpatient Health Plan (PIHP) managed care program that is paid using capitation. This program does not include behavioral health services.2008 National Summary of State Medicaid Managed Care Programs -- page 1No significant issues.
Alaska (AK) NANANANA62.9% of enrollees indicated to have private health insurance coverage. Only 56.7% of claims in the OT file have a primary diagnosis code.
Arizona (AZ)X XState carves MH & SA services from the HMO, yet also has a BHO.2008 National Summary of State Medicaid Managed Care Programs -- page 205No significant issues.
Arkansas (AR) NANANANAIP claims have a maximum of 2 DX codes only. 2.1% of records have no eligibility information. Identification of private insurance coverage is unreliable.
California (CA)XXXCA has a statewide FFS MH plan covering specialty MH services for all that meet medical necessity criteria, but county MH departments have the first right of refusal to serve as the MH plan. The Partnership Health Plan of CA HIO & the Sacramento Geographic managed care organization (MCO) include inpatient/outpatient MH. The San Diego Geographic MCO, the AIDS Healthcare MCO, & the Prepaid Health Plan (PHP) Program MCO include outpatient MH. The Senior Care Action Network MCO includes inpatient MH/substance use disorder (SUD) & outpatient MH. The Caloptima HIO, the Central Coast Alliance for Health HIO, the Health Plan of San Mateo MCO, the Santa Barbara San Luis Obispo Regional Health Authority HIO, & the Two-Plan Model Program MCO carve out MH services.2008 National Summary of State Medicaid Managed Care Programs -- pages 11, 16, 24, 29, 31, 36, 41, 359, 365, 370, 506, 514, & 520IP claims only have a maximum of 2 DX codes & LT claims only 1.
Colorado (CO)XX State carves out MH service from MCO. Has an MH PIHP that does not specifically mention SA services but includes a fairly comprehensive list of MH services.2008 National Summary of State Medicaid Managed Care Programs -- pages 42, 527No significant issues.
Connecticut (CT)XX CT's Husky A has an MH ASO that covers SUD services.2008 National Summary of State Medicaid Managed Care Programs -- page 49CT's HMOs ceased providing services to Medicaid enrollees from December 2007 through July 2008, so there was no HMO enrollment during this period.
Delaware (DE)X XDE's Diamond State Health Plan MCOs cover SA services.2008 National Summary of State Medicaid Managed Care Programs -- page 218No significant issues.
District of Columbia (DC)X XDC Medicaid Managed Care Program (comprehensive benefits, risk-based capitation) includes services for inpatient MH & SA & outpatient MH (does not mention outpatient SA).2008 National Summary of State Medicaid Managed Care Programs -- page 375In the LT file, only 9.3% of claims have a primary DX code.
Florida (FL)X XFL has 2 MCOs: Managed Health Care MCO includes inpatient MH/SUD & MH targeted case management, & Florida Medicaid Reform MCO includes community MH services, inpatient/outpatient MH/SUD services, & outpatient MH. The state also has an MH PIHP, a Statewide Inpatient Psychiatric Program, & a Shared Savings Model that covers community MH.2008 National Summary of State Medicaid Managed Care Programs -- pages 57, 61, 63, 72, 225In the LT file, only 32% of claims have a primary DX code; in the OT file only 78.3% do. Correctable mismatch between claim & eligibility file MSIS-IDs. LT & Medical--Only PIHPs reported in CMS data but not MAX.
Georgia (GA)X XGA has an MCO that covers inpatient/outpatient MH/SUD services. The state also has a BHO, which became FFS in 2007. Preadmission Screening & Annual Resident Review (PASARR) program ceased operating as a MH PIHP on September 30, 2007. Effective October 1, 2007, this program uses only 1915(b)(4) authority solely for FFS reimbursement arrangement.2008 National Summary of State Medicaid Managed Care Programs -- pages 73, 384In the OT file, only 94.8% of claims have primary diagnosis codes. Individuals in a MH PIHP 1915b waiver program were incorrectly assigned to primary care case management (PCCM) instead of PHP. This error is correctable.
Hawaii (HI)X XHI QUEST Expanded (QEx) MCO & MH/SUD PIHP cover all MH & SUD services (risk-based capitation). If enrollee is in both, it is unclear who pays for SA services.2008 National Summary of State Medicaid Managed Care Programs -- page 2343.3% of records missing eligibility information. In the OT file, only 75.2% of claims have a primary diagnosis code.
Idaho (ID) NANANANANo significant issues.
Illinois (IL)X XIL's Voluntary Managed Care includes inpatient/outpatient MH & SUDs through the MCO.2008 National Summary of State Medicaid Managed Care Programs -- page 538No significant issues.
Indiana (IN)X XUnder Hoosier Healthwise, all MH & SA services are covered through the MCO. Under HIP, inpatient SA is covered, but there is no mention of MH services or outpatient SA.2008 National Summary of State Medicaid Managed Care Programs -- pages 77 & 243No significant issues.
Iowa (IA)XX All services are through the BHO; none provided through the HMO. By February 2005, only 1 HMO was left in the state. As of February 2009, enrollment in this HMO ended.2008 National Summary of State Medicaid Managed Care Programs -- page 393In the LT file, only 88% of claims have a primary diagnosis code. Only 96.6% of managed care enrollees have capitation payments reported.
Kansas (KS)XX MCO does not cover MH/SUD services. State has SUD PIHP & MH PAHP.2008 National Summary of State Medicaid Managed Care Programs -- pages 402 & 620BHP-ASO (Administrative Services Only) benefit, which covers only administrative costs of coordinating MH benefits, not benefits themselves, is not recorded in Claims or Eligibility data.
Kentucky (KY)XX KY Health Care Partnership Program MCO does not cover MH or SUD services, with the exception of inpatient medical detoxification.2008 National Summary of State Medicaid Managed Care Programs -- page 248Private health insurance reporting unreliable before October 2008.
Louisiana (LA) NANANANAPrivate health insurance reporting may be unreliable in 2008. In the LT file, only 86.9% of claims have primary DX code.
Maine (ME) NANANANAME was unable to report accurately its IP/LT/OT claims, as it did not have a fully functional MMIS. The MAX 2008 files contain only the RX & eligibility information.
Maryland (MD)X XMD's HealthChoice MCO includes coverage for inpatient/outpatient SUDs.2008 National Summary of State Medicaid Managed Care Programs -- page 255In the LT file, only 63.7% of claims have primary DX code. Only 88.1% of managed care enrollees have capitation claims.
Massachusetts (MA)X XMA's Mass Health covers services under 'MH/SUD PIHP -- Risk-based Capitation,' (this is their BHO) & 'MCO (Comprehensive Benefits) -- Risk-based Capitation.' If enrollee is in both, it is unclear who pays for services.2008 National Summary of State Medicaid Managed Care Programs -- pages 262–264MAX 2008 contains only claims adjudicated through Q2 FY 2009. In the LT file, only 7.9% of claims have a primary diagnosis code; in the OT file, only 44.6% do. A high percentage (24.7%) of MA enrollees have private health insurance. Only 94.4% of managed care enrollees have capitation payments.
Michigan (MI)X XMI's Comprehensive Health Plan includes outpatient MH services under the MCO. MI's Specialty PIHPs (the BHO) include SA services. It appears the BHO pays for SA services, but if enrollee is in both, it is unclear who pays for MH services.2008 National Summary of State Medicaid Managed Care Programs -- pages 87, 629In the OT file, only 79.5% of claims have primary diagnosis codes. Only 95% of managed care enrollees have capitation claims.
Minnesota (MN)X XMN's Consolidated Chemical Dependency Treatment Fund includes SA inpatient & outpatient services under the County Case Manager program paid FFS. MN's Prepaid Medical Assistance Program--1115(a), MinnesotaCare Program For Families & Children, MN Prepaid Medical Assistance Program--1932(a), MN Disability Health Options (MnDHO), MN Senior Health Options Program (MSHO), Special Needs Basic Care, & MN Senior Care/MN Senior Care Plus all include services for inpatient/outpatient SA.2008 National Summary of State Medicaid Managed Care Programs -- pages 93, 273, 279, 417, 543, 548, 553, 634Through September 2008, some aliens eligible only for emergency services may have been reported to RBF 5. MN moved these individuals to RBF 2 in October 2008.
Mississippi (MS) NANANANANo significant issues.
Missouri (MO)X XMO's HealthNet Managed Care program includes MH/SA services.2008 National Summary of State Medicaid Managed Care Programs -- page 96No significant issues.
Montana (MT) NANANANASome individuals in UEGs 11-12, 22, 34-35, 42, 44, & 48 may have been incorrectly assigned RBF 5.
Nebraska (NE)XX NE Health Connection Combined Waiver Program--1915(b) includes adult SA treatment & inpatient & outpatient MH services under the Specialty Physician Case Management (SPCM) Program. The MCOs under this program do not cover MH/SA services.2008 National Summary of State Medicaid Managed Care Programs -- page 108No significant issues.
Nevada (NV)X  NV's Mandatory Health Maintenance Program includes inpatient/outpatient MH services under the MCO. SA is not mentioned.2008 National Summary of State Medicaid Managed Care Programs -- page 428No significant issues.
New Hampshire (NH) NANANANAIn the OT file, only 79.3% of claims have primary diagnosis code. DMP plan not reported in MAX data.
New Jersey (NJ)X XNJ FamilyCare--1915(b) & NJ FamilyCare --1932(a) include inpatient/outpatient SA services under the MCOs.2008 National Summary of State Medicaid Managed Care Programs -- pages 116 & 437No significant issues.
New Mexico (NM)XX NEW MEXICO SALUD! Includes services under the MH PIHP, a BHO for MH services. SA services are not mentioned specifically.2008 National Summary of State Medicaid Managed Care Programs -- page 124In the OT file, only 54.7% of claims have primary diagnosis codes.
New York (NY)X XNY's Federal-State Health Reform Partnership (F-SHRP), F-SHRP--Medicaid Advantage, Partnership Plan--Family Health Plus (both MCO & PPO), & Partnership Plan Medicaid Managed Care Program include inpatient/outpatient substance misuse services under the MCOs.2008 National Summary of State Medicaid Managed Care Programs -- pages 284, 292, 296, 298, 301Only 92.2% of managed care enrollees had capitation claims.
North Carolina (NC)X XNC's Piedmont Cardinal Health Plan, a BHO, covers MH & SUD services. This plan operates in only 5 counties in the state.NANo significant issues.
North Dakota (ND) NANANANANo significant issues.
Ohio (OH)X XOhio's full-risk managed care program includes both inpatient & outpatient SA services.2008 National Summary of State Medicaid Managed Care Programs -- page 453In the LT file, only 88% of claims have a primary diagnosis code;
Oklahoma (OK) NANANANAIn the LT file, only 89.3% of claims have a primary diagnosis code; some of the diagnosis codes may have an extra 0 or 2 because this field is not edited by the state.
Oregon (OR)X XOR MH/SUD PIHP is the state's BHO & includes SA services. OR also has an MCO program that includes SA services. It is unclear who would pay for services if enrollee is in both BHO & HMO.2008 National Summary of State Medicaid Managed Care Programs -- pages 317 & 320In the OT file, only 50.6% of claims have a primary diagnosis code.
Pennsylvania (PA)XX PA has a BHO that appears to cover all SA services. The HealthChoices MCO program does not cover these services.2008 National Summary of State Medicaid Managed Care Programs -- page 143In the OT file, only 79.9% of claims have primary diagnosis codes. The diagnosis code on some EPSDT screens is "EPSDT."
Rhode Island (RI)X XRI's Rite Care program includes inpatient & outpatient SA services. Also, RI's Rhody Health Partners program includes inpatient & outpatient SA services.2008 National Summary of State Medicaid Managed Care Programs -- page 329Private insurance enrollment information is not reliable.
South Carolina (SC)XXXSC's HMO program includes alcohol & drug screening & physical exams through the Department of Alcohol & Drug Abuse Services; however, no mention of inpatient/outpatient SA services. SC also has a Medically Fragile managed care program, which excludes these services. Palmetto Physician Connections Offers a special MH & SA program. The other HMOs do not offer this program.2008 National Summary of State Medicaid Managed Care Programs -- page 591In the LT file, only 4.3% of claims have a primary diagnosis code; in the OT file, 70.4% do.
South Dakota (SD) NANANANAIn the LT file, only 2.7% of claims have primary diagnosis code. Only 96.2% of managed care enrollees have capitation payments.
Tennessee (TN)X XTN's MH/SUD PIHP is the state's BHO & includes SA services. However, the state's MCOs in the TennCare program also include inpatient & outpatient services. It is unclear if an enrollee is enrolled in both plans, which covers SA services.2008 National Summary of State Medicaid Managed Care Programs -- pages 335 & 337No significant issues.
Texas (TX)X XTX has an MH/SUD PIHP, its BHO, known as NorthSTAR. However, this BHO is reimbursed with a combination of FFS & risk-based capitation (mostly FFS). It is unclear what services are included in the capitation payment.TX also has risk-based MCOs, (the STAR, STARHealth, & STAR+PLUS programs) that include inpatient & outpatient SA services.State has a disease management program, TX Medicaid enhanced program, which does not include SA. This program is not coded as HMO in data.2008 National Summary of State Medicaid Managed Care Programs -- pages 157, 163, 601, & 649In the LT file, only 89.9% of claims have a primary diagnosis code; in the OT file, only 66.2% do. TX submits a few HMO capitation claims with a type of claim of FFS, instead of capitation. These are premium payments for private health insurance (OT). 2.5% of claims are missing eligibility information. Only 95.2% of managed care enrollees have capitation claims.
Utah (UT) NANAUT's Prepaid Mental Health Program covers MH services. There is no discussion of SA.NAMAX 2008 contains only claims adjudicated through Q1 FY 2009. 3.9% of claims are missing eligibility, & these are primarily capitation claims. In the OT file, only 78.8% of claims have primary diagnosis code. 3.9% of claims are missing eligibility information, & these are primarily capitation claims.
Vermont (VT) NANANANANo significant issues
Virginia (VA)X XVA's Medallian MCO program includes inpatient MH & outpatient SA services.2008 National Summary of State Medicaid Managed Care Programs -- page 189From Q2 2007 to Q3 2008, 7,000-11,000 HMO enrollees were reported with 0-filled plan IDs. The state indicated that these people were not actually enrolled in HMOs. Only 94.7% of managed care enrollees have capitation payments.
Washington (WA)XXXWA has a BHO known as the Integrated Mental Health Services program -- it is not clear whether this program covers SA services, as they are not mentioned specifically. WA also has MCOs in the WA Medicaid Integration Program (WMIP) that cover inpatient & outpatient SA services. It is not clear who covers SA costs when individuals are enrolled in both.MCOs in the Healthy Options program do not cover SA services.2008 National Summary of State Medicaid Managed Care Programs -- pages 194 & 482In the LT, file only 19.9% of claims have a primary diagnosis code; in the OT file, only 71.3% do.
West Virginia (WV)XXXWV's Mountain Health Choices covers inpatient MH & outpatient MH. There is no mention of SA.WV's Mountain Health Trust MCOs do not cover any MH or SA services.2008 National Summary of State Medicaid Managed Care Programs -- pages 198 & 703.DX codes are missing on most LT claims.
Wisconsin (WI)X XWI MCOs in the BadgerCare Plus, Medicaid SSI Managed Care, & WI Partnership programs include inpatient & outpatient SA services. The state also has a BHO in the Children Come First & Wraparound Milwaukee programs that provides SA services. If individuals are enrolled in both the BHO & MCO, it is unclear who covers their SA services. In addition, WI has a long-term care PIHP program (1915(b)(c) waiver) that is risk-based & includes outpatient SA services.2008 National Summary of State Medicaid Managed Care Programs -- pages 487, 493, 498, 606, 610, 655WI was unable to report all of its claims by the prescribed deadline. The MAX 2008 files contain only claims adjudicated through Q3 FY 2009. RBF assignments became unreliable starting in October, when WI implemented a new MMIS, causing some enrollees to be mapped to incorrect RBF assignments. Only 97.4% of managed care enrollees have capitation claims.
Wyoming (WY) NANANANANo significant issues.