The Department of Administration, n.d.). Jean Ann

The South Carolina Title XIX
State Plan, also known as Medicaid, was designed to maintain the provision of “quality health care to low income, disabled,
and elderly individuals” (South Carolina Department of Health and Human
Services, 2016).  The South Carolina
Department of Health and Human Services (SCDHHS) acts as the designee for this
administration, managing the state and federal reimbursement of funds for
approved medical providers.  Services are
designed to provide services for diagnosis, treatment, and management of
illnesses.  The Management Care Organization
program provides insurance coverage through a network comprised of contracted,
providers who are paid a “per member per month capitated rate” (SCDHHS, 2016).  These organizations must, at a minimum,
provide services as outlined in the general core benefit package but may
enhance services if they so choose. 

Mental Health America

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The Mental Health America (MHA) website
describes their organization as a “community-based nonprofit… dedicated to
addressing the needs of those living with mental illness and…promoting the
overall mental health of all Americans” (2017b).  With more than 200 affiliates, 6,500
affiliate staff and 10,000 volunteers, MHA is nationally recognized for their
initiatives promoting overall mental wellness, preventative and early
identification measures, integrated care services, recovery-focused supports,
“advocacy, education, and research” (MHA, 2017b).  Their work is guided by the Before Stage
4 philosophy which poses we should invest the same preventative measures
we would for illnesses such as cancer, heart disease, or diabetes, for people
experiencing initial symptoms of serious mental illnesses, as well (MHA, 2017a).  MHA states the current Medicaid funding models
overlook how comprehensive community-based services enable people to thrive,
thus fostering savings for the state. 
They pose, regardless of funding outlet, an unbiased model would allow
coverage of “preventive services …in schools, homes, and communities…Evidence-based
psychoeducation and support to…individuals other than the beneficiary…an
expansion of the Medicaid Free Care …to all health plans.”

Policy Changes

Managed Care Organizations

On July 1, 2016, the South Carolina Department of Health and Human Services (SCDHHS) amended
the Medicaid policy, outsourcing insurance coverage for Rehabilitative
Behavioral Health Services (RBHS) to private MCO’s (South Carolina Department
of Administration, n.d.).  Medicaid
allotted a 90-day grace period for coverage of previously approved services, to
prevent discontinuation of services, at the end of which five private MCO’s
(SelectHealth, Molina, WellCare, BlueChoice and Absolute and total care) were
permitted to deny coverage for services outside of their network (South
Carolina Department of Administration, n.d.). 

Jean Ann Lambert, Community Resource Director
at Mental Health America, granted me an interview on November 10, 2017,
describing the impact this policy change has had on the organization.  Mrs. Lambert stated the organization,
initially, had to advocate for an extension of time required to transfer services
as they were initially only provided 30 days. 
“It was very difficult because the way the system was set up, we had
no idea who to talk to.  The Medicaid
office didn’t really help.  They just
said, ‘go to them’ and gave us names and numbers.  We had no idea who they were, and they didn’t
know who we are.”  Gratefully, the
organization was allowed an added two months, totaling a 90-day transition
period.  It seemed policy implementation
began with turbulence, but initiation of services was not the only problem MHA
faced.  “Some didn’t have a behavioral
health fee,” Mrs. Lambert continued, “only physical health.  They called our agency to figure out what to
do…to find out more about us.” According to the Mental Health Parity and
Addiction Equity Act, the bill under which this title is placed, mental health
and substance use disorder coverage is not mandated, although approximately 12% of beneficiaries over 18 have
a substance use disorder (Medicaid,
2017; Medicaid, n.d.).

Stringent Requirements

Furthermore, the SCDHHS website notes that beneficiaries receiving these
services after the transition must have a medical necessity review
listed in their diagnostic assessment. 
This review, placed solely on conditions related to mental health,
damaged MHA’s ability to provide a portion of their services due to a decrease
in diagnoses being covered.  “It’s more
stress to get the paper work done and get the diagnosis through,” explained
Mrs. Lambert, “making it harder for us to care for the clients by making
certain diagnoses appropriate.  Some
clients can’t be served.  We eat some of
the cost, because we have a heart, but it hurts our agency.” Additional
disruptions in services ranged from inadequate reimbursement rates forcing
services to be provided out-of-network, lack of residential or intensive
outpatient care coverage, and refusal to authorize payment for inpatient detox treatment
for those being treated with an opioid addiction (MHA website).

The interview further revealed the stringent
paperwork requirements added to the tasks they already had.  “It’s like a 4-page form just to get the
initial paper work through.  Then, you
have to do a 5-page assessment, followed by a 1-page essay to justify why
they need the program.  Then background
information and a diagnosis from the mental health center.  We send that through, and 50% of the time
they deny it and want something more.” A review of the policy revisions listed
on the SCDHHS quickly validates Mrs. Lamberts
concerns.  In addition to
documentation for medical necessity, a 90-day summary is required for
continuity of services, a five-day limit is placed on insertion of clinical
service notes into the medical records, a 30-day limit for the individualized
plan of care (IPOC), a discharge plan of action added to the IPOC followed by a
documented discharge summary, as well as a Behavior Modification Plan.  Further, family
support services are eliminated once the beneficiary passes the age of 21.  Note these revisions are simply an overview
and not explanation of all revisions.

Beneficial or not?

It is difficult to see how the policy
expansion has worked to make things easier or, fairer, for community providers,
especially, to effectively treat those struggling with mental health or
substance use disorders.  In theory, policy changes made have made it so that individuals
with mental health or substance use disorders have better coverage of care than
before.  However, as evidenced above,
they have fallen short of their goal. Mrs. Lamberts last words reverberate the
truth of the actual impact this policy change has made.  “They enjoy it because
they get more money.  We are a small
nonprofit; we are probably more trouble that its worth opposed to the State
Department of Mental Health.  It’s been a
struggle for them too.  It’s just been a
lot harder to get all of the money through.”