Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States. E. Covered Populations and Services


Populations. Magellan manages behavioral health services for adults enrolled in Medicaid (including those dually eligible for Medicare) and for non-Medicaid adults eligible for OBH services. OBH projected that 164,360 non-disabled adults and 133,050 disabled adults would be eligible for 1915(b) services under the Magellan contract in the second year of the program (DHH 2011).

There is not a separate process for enrolling adults into services managed by Magellan. Rather, adult Medicaid beneficiaries automatically have their behavioral health care managed by Magellan. Individuals who are not currently enrolled in Medicaid or who are not eligible for Medicaid can go directly to a provider. The provider is then responsible for contacting Magellan to determine if the individual is eligible for behavioral health services and to obtain any necessary authorizations for provider services. Alternatively, individuals in need of behavioral health services can contact Magellan directly, as described below, to determine their eligibility for services and be connected with a provider.

Services. Medicaid and non-Medicaid-eligible adults have access to a range of services. Coverage for services differs across Medicaid subpopulations; notably, those eligible for 1915(i) services (those who meet the federal definition for SMI) have access to a broader array of rehabilitation services and case-conferencing services than the medically needy or other Medicaid adults. For non-Medicaid-eligible adults, Magellan is not responsible for covering inpatient psychiatric stays in general hospitals, but it does cover stays in psychiatric hospitals.

Table III.1 summarizes which services Magellan manages by covered populations.

TABLE III.1. LBHP Services Provided Through Capitated Managed Care, by Covered Populations
    Medicaid Adults     Medicaid Adults Eligible  
for 1915(i) Services
(adults with SMI)
  Medically Needy   Non-Medicaid-
  Eligible Adults  
Inpatient psychiatric stays in general hospitals X X X  
Stays in psychiatric hospitals X (over age 65)     X
Psychiatrists X X X X
Other licensed mental health practitioners   X    
Rehabilitation (unlicensed mental health practitioners)a     X   X
Rehabilitation for substance abuse X X   X
Case-conferencing   X   X
  1. This category includes community psychiatric support and treatment, psychosocial rehabilitation, and crisis intervention.

In addition to inpatient care, Magellan manages a range of outpatient and rehabilitative services. These services, explained below, have specific eligibility and prior-authorization requirements, as described in the service definition manual available on the LBHP website (DHH 2012a).

  • Case-conferencing refers to face-to-face meetings between providers to discuss treatment or treatment plans. Only licensed mental health practitioners (LMHPs), advanced practice registered nurses (APRNs), and psychiatrists can receive reimbursement for case-conferencing. (LMHPs are licensed by the state and typically include psychologists, clinical social workers, licensed professional counselors, marriage and family therapists, addiction counselors, and APRNs.) Case-conferencing is intended to coordinate treatment across agencies rather than to pay for treatment team meetings within an agency.

  • Psychosocial rehabilitation is designed to eliminate functional deficits and interpersonal or environmental barriers associated with mental illness so that the individual can remain in the community. These services can be delivered by providers who have at least a high school diploma.

  • Community psychiatric support and treatment (CPST) is intended to help individuals achieve their goals and live independently through individual supportive counseling, solution-focused interventions, and assistance with daily living skills. Practitioners with a master's degree can provide any CPST service, while those with a bachelor's degree (or equivalent) can provide only some CPST services. Peer specialists can also provide some CPST services.

  • Crisis intervention services are intended to ameliorate psychiatric emergencies through preliminary assessment, resolution of immediate problems, and referral and linkage to appropriate community services. Some crisis intervention services can be provided by an individual with at least an associate's degree in human services, while others can be provided only by LMHPs.

Magellan does not currently provide supportive housing services, but it anticipates taking over the management of a supportive housing program from OBH in 2013. This program will provide supportive housing for approximately 3,300 individuals, primarily in areas that were affected by Hurricane Katrina and Rita that were original funded by federal legislation for Gulf Opportunity Zone redevelopment. Magellan will employ "tenant service managers" to assist program participants with daily living skills so they can maintain their housing and live independently. OBH and Magellan hope to bring managed care practices to the supportive housing model in order to increase its efficiency and to better coordinate other behavioral health services that can help individuals maintain their housing. Via the Magellan contract, Medicaid and non-Medicaid funding may be used for various services for the population in supportive housing.

Physical health services and pharmacy benefits for Medicaid beneficiaries are delivered through separate managed care arrangements, known collectively as Bayou Health. At the time of this study, Magellan and the physical health plans did not share data on consumers, and there were no formal mechanisms for coordinating physical and behavioral health services. Nevertheless, care managers from Magellan and the physical health plans do interact with each other to coordinate care. Given that Magellan is at-risk for behavioral health services, Magellan care managers have an incentive to coordinate with physical health providers and supportive services providers outside of Magellan's financial responsibility so that costly hospital psychiatric stays can be avoided. One of Magellan's current quality-improvement efforts seeks to strengthen care coordination with physical health providers, and eventually information may be shared between plans. OBH and Magellan are also planning to allow physical health providers to securely download patient information from Magellan's databases to facilitate better care planning and coordination.

Building the provider network. OBH and Magellan are working to expand the provider network, in part by allowing licensed professional counselors and licensed clinical social workers to receive Medicaid reimbursement via Magellan under the terms of the state plan option for 1915(i) services. Magellan credentials providers every three years in accordance with National Committee for Quality Assurance (NCQA) standards. Depending on licensure and education level, providers can be credentialed independently, or they can receive reimbursement working as part of a credentialed organization. Providers who had a Medicaid provider identification number at the time OBH contracted with Magellan did not have to actively enroll in the Magellan network. Rather, they were automatically enrolled and put through the credentialing process. Other providers who already had a contract with Magellan but did not serve Medicaid beneficiaries had to amend their contract with Magellan to bill for Medicaid and non-Medicaid adults.

All providers now must submit claims to Magellan. Previously, many behavioral health providers were not accustomed to billing Medicaid or other insurers. For behavioral health services provided after March 1, 2012, providers must submit a claim via the Clinical Advisor electronic health record (EHR), described below, or use an electronic claims submission available on Magellan's website, or submit a paper claim. Magellan only accepts claims from Magellan credentialed providers. Therefore, behavioral health services delivered in primary care would be submitted to the physical health plans.

Navigating services. There are several mechanisms to help consumers navigate services. Magellan staffs a toll-free number that consumers can call 24 hours a day, seven days a week, to speak with a care manager about accessing behavioral health services. The care manager conducts an initial assessment of the consumer's needs and eligibility for services and then connects the consumer with service providers. Magellan incurs a financial penalty for not answering calls within 30 seconds and for losing calls (calls terminated by the consumer waiting in queue). Magellan also maintains a website ( with providers' locations and contact information.

For adults diagnosed with SMI and eligible for 1915(i) services, Magellan contracts with clinicians who conduct independent assessments and develop treatment plans, which include recommendations for length and type of treatment. These assessments are not conducted by treatment providers but by independent assessors who have a contract with Magellan specifically for this purpose. For other adults, any provider in the Magellan network can conduct an assessment and develop the treatment plan. Magellan reviews the assessments for 1915(i) services, as well as treatment plans for other adults, and then authorizes care for a maximum period of three months. After three months, the provider must seek reauthorization. Consumers can receive up to five diagnostic assessments, 24 outpatient psychotherapy sessions, and 12 medication management sessions per year without needing prior-authorization (Magellan Health Services 2012).

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