Medicaid Managed Care - U.S. Senate Special Committee on Aging

755
Protecting Consumer Rights in Public Systems'
MANAGED MENTAL
HEALTH CARE POLICY
A Series of Issue Papers on Contracting for <strong>Managed</strong> Behavioral Health <strong>Care</strong>
#1
DEFUNII
"MEDIC
NECESS
SERVIC)
TO PRO
PLAN
MEMBEF
March 1997
VG A s <strong>Medicaid</strong>, mental health and child welfare systems are red-
ALLY
bARY
signed to adopt a managed care approach to the organization and delivery
of services, important shifts occur in how services for adults and
children with mental health care needs are regulated. This paper has
been prepared by the Bazelon Center for Mental
Center
Health Law
for
for the
Mental Health Services and concerns public agency contracts
for managed behavioral health care.
This paper addresses a critical part of any such contract, the defini-
TECT
tion of what is a medically necessary service and the procedures used to
determine when a service is medically necessary. Medically necessary
criteria should require that services are designed to achieve appropriate
goals and delivered in a manner adhering to state standards and principles.
The criteria should result in appropriate access to the defined bene-
ILS fit package.
The paper is designed to assist consumers, families and advocates, as
well as policymaklers, to ensure that medically necessary standards in
public-sector contracts for managed mental health care' protect consumers.
It particularly emphasizes the rights and needs of adults with serious
mental illness and children with serious emotional disturbance.
BACKGROUND
Historically, public sector mental health services have been funded
either through fee-for-service reimbursement or with funds received under
a grant from local, state or federal governments. Now, increasingly,
governments at 2lleves7 are moving toward contracting out management
of the mental health system, and often the entities entering into
these contracts are private for-profit companies. In some states they are
A POLICY ANALYSIS SERIES FROM THE BAZELON CENTER FOR MENTAL HEALTH LAW
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