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

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(6J identify and evaluate a mental illness that is suspected
(c) treat, ameliorate, diminish or stahilize symptoms of mental illness, including
impairment infunctioning,
(d) alleviate suffering or pain;
(e) prevent arrest or delay the development or progression of a mental illness
and to prevent or delay relapse;
O) provide rehabilitation to enable the Member to attain or maintain an
optimal level offunctioning (includingfunctioning in all important areas
of if4 such as daily activities, social relationships, and independent livingA
(gl affirmatively ensure access to and promote appropriate utilization of
services (including overcoming harriers cassed by inability to obtain trans.
portation).
C. Standards of Service Delivery
In addition to describing the goals and purposes of services, the defnition
of 'medically necessary' should ensure compliance with important
services delivery standards. For example, the definition should
make clear that medically necessary services must be responsive to members'
unique needs, provide choice among possible alternatives, and be
furnished in an appropriate manner. Such standards are-incorporated
into law in many states or reflected in mental health system planning
documents.
Medically necessary services must be:
(a) hased upon an individualized assessment of the individual's assets,
strengths, desires, needs and environmental supports;
(b)furnished in accordance with an individualized services plan, which
is based on a comprehensive assessment, developed in partnership with the
-Member (or in the casiof a child, rA-hild to the extentfeasible and the
chid's family) and designed to attain specific outcomes desired by tie Memher;
the services plan shall be monitored, reassessed and revisedperiodically,
basd on progress, outcomes and consumer satisfaction; Memners shall e
given ultimate authority to review and approve the services plan;
(c) services of the Member's choice (or, in the case of a Member child unable
to make choices, services of the Member'sfamily's choice). T7e Member
has the right to refuse services consistent with law and such refusal may-notbe
used as grounds to deny other services; the plan may deny services that
wouid be ineffective orfor which there is a cost-eftive alternative that oth
Defining "Medically Necessary' Services to Protect Plan Members
POLICY ANALYSIS BY THE BAZELON CENTER FOR MENTAL HEALTH LAW 14