Federal Reports

The State agency is responsible for administering the Medicaid program, including processing and paying claims for behavioral health services. Its goal is to facilitate quality health care services that will produce positive health outcomes for Oklahoma. The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) has oversight responsibility for behavioral health services in Oklahoma. Its mission is to promote healthy communities and provide the highest quality care to enhance the well-being of all Oklahomans. ODMHSAS is primarily State funded (approximately 71 percent); the rest of its funding comes predominantly from Medicaid for individual beneficiary services (17 percent) and Federal grants (11 percent).The State agency and ODMHSAS have an interagency agreement to ensure that individuals being served by both organizations receive appropriate behavioral health care and to provide reimbursement to ODMHSAS for administrative costs, among other things. The agreement identifies the various roles each organization performs in providing and overseeing behavioral health in Oklahoma.The State agency has four key control activities to ensure that behavioral health services meet State requirements: (1) provider enrollment, (2) behavioral health program integrity audits, (3) claim processing edits, and (4) pharmacy requirements for medications used to treat OUD (OUDdrugs).ODMHSAS also has four key control activities to ensure that behavioral health services meet State requirements: (1) certification of agencies that provide services, (2) annual contract reviews at agencies that provide services, (3) beneficiary prior authorization to receive services, and (4) automated claim analyses to ensure that paid claims meet certain payment rules.Counseling helps people with OUD change how they think, cope, and react, and acquire the skills and confidence needed for recovery. CMS, numerous addiction treatment authorities and nationally recognized evidence-based guidelines, such as the American Society of Addiction Medicine’s (ASAM’s) National Practice Guidelines for the Use of Medications in the Treatment of Addiction Involving Opioid Use, and SAMHSA’s Treatment Improvement Protocol (TIP) 40 indicate that counseling for individuals taking OUD drugs can be helpful in treating OUD.8 SAMHSA’s TIP 63, Medications for Opioid Use Disorders, indicates that although counseling greatly benefits many patients, treatment should target the patient’s needs and, therefore, counseling should not be required.ODMHSAS’s objectives include providing the highest quality care to enhance the well-being of all Oklahomans. To help ensure quality of care and fulfill its oversight role of behavioral health services, ODMHSAS performs annual reviews at outpatient facilities that contract with it to provide the services. During the reviews, ODMHSAS staff evaluate a random sample of 10 non- Medicaid client files to ensure that the facilities appropriately provided and documented their services. ODMHSAS determines whether the services were performed, and it reviews clinical records to determine whether the services were individualized and were client and assessment driven. Review of clinical documentation may include, but not be limited to, screenings, assessments, treatment plans, corresponding progress notes, and other documentation, as necessary.

Missouri’s Medicaid Health Home ProgramMissouri has operated a Medicaid health home program since calendar year (CY) 2012. Health home providers directly provide health home services to eligible and enrolled beneficiaries. The State agency is primarily responsible for monitoring and overseeing the health home program. The State agency’s monitoring activities include determining whether health home providers have documentation that enrolled beneficiaries met the eligibility requirements discussed above and that the beneficiaries received health home services as defined in the relevant SPAs.The State agency administers two health home programs: a Primary Care Health Home (PCHH) and a Community Mental Health Center Healthcare Home (CMHC). Both programs require health home providers to furnish at least one core service (discussed below) to enrolled beneficiaries.The State agency made payments to health home providers using a payment model that allowed those providers to bill the State agency and receive a per member-per month (PMPM) payment for providing at least one health home service to a Medicaid beneficiary for a month. Core Health Home ServicesHealth home providers must furnish at least one of the six core services per month to receive a PMPM payment (SPA MO 11-0011, SPA MO 11-0015, SPA MO 16-0002, and SPA MO 16-0007): • comprehensive care management, which includes assessing preliminary service needs, developing treatment plans, and monitoring individual and population health status; • care coordination, which includes referring beneficiaries to long-term services, appointment scheduling, conducting referrals and followup monitoring, and participating in hospital discharge processes;• health promotion, which includes providing health education specific to an individual’s chronic conditions, developing self-management plans with the individual, and providing support for improving social networks; • comprehensive transitional care from inpatient care to other settings, which includes providing care coordination services designed to streamline plans of care and reduce hospitalizations; • patient and family support, which includes advocating for individuals and families, assisting with obtaining and adhering to medication, and identifying resources for patients; and• referrals to community and social support services, which include providing assistance for clients to obtain and maintain eligibility for health care, disability benefits, housing, and legal services. Primary Care Health Home ProgramThe PCHH program covers enrolled beneficiaries who have two or more chronic conditions or have one chronic condition and are at risk of developing another. The PCHH program defines qualifying chronic conditions as asthma; mental health conditions, including anxiety and depression; substance use disorder; developmental disabilities, diabetes, heart disease, and high body mass index. At-risk conditions include tobacco use, diabetes, pediatric asthma, and obesity (SPA MO 11-0015 and SPA MO 16-0002). Community Mental Health Center Healthcare Home ProgramThe CMHC program covers enrolled beneficiaries who have two or more chronic conditions, one chronic condition and the risk of developing another chronic condition, or one or more serious and persistent mental health condition (SMI). An SMI is a diagnosis of schizophrenia, delusional disorder, bipolar disorder, psychotic disorder, reoccurring major depressive disorder, obsessive-compulsive disorder, post-traumatic stress disorder, or borderline personality disorder (SPA MO 11-0011 and SPA MO-16-0007). Health home providers receive one payment for PCHH beneficiaries and one payment for CMHC beneficiaries.