Pennsylvania Mental Health and Substance Abuse ... - SAMHSA Store

PennsylvaniaData as of July 2003per 365-day periodInpatient Psychiatric Services (for persons under the age of 25)Service Description Coverage RequirementsInpatient PsychiatricFacility Services forindividuals under 22years of ageEvaluation, diagnostic and treatment services Provided without LimitationRehabilitative ServicesService Description Coverage RequirementsFamily-Based MentalHealth RehabilitativeServicesMental Health CrisisIntervention ServicesCommunity BasedMental HealthRehabilitativeServicesComprehensive mental healthservice provided primarily in thehome of a child or adolescent,including• assessment,• planning,• treatment (includingpsychotherapy/counseling(individual, group, and family);• play therapy;• recreational therapy;• behavior modeling andmodification;• cognitive therapy;• rational/emotive therapy;• reality therapy;• communication skills;• coping skills;• assertiveness training;• parenting skills;• sensitivity training; and• supportive services.Services include intervention,assessment, counseling,screening, and disposition.Services include psychiatric,medical, and psychological testing;art therapy, movement therapy,and music therapy; psychotherapyand counseling (includingindividual, group, and family);rehabilitation services; andmedication management.• To qualify for services a beneficiary must- Be under age 21- Have a mental illness or a serious behaviordisorder- At risk for psychiatric hospitalization andother out of the home placements.• Beneficiaries may only receive services fromproviders that are licensed as family basedmental health rehabilitative providers.• Services must be recommended by a physicianor licensed psychologist.• Services limited to a 32-week period starting onthe first date of service. Extensions must beapproved by the Department and deemedmedically necessary.• Beneficiaries must receive services fromproviders that are licensed as mental healthcrisis intervention providers• Services must be ordered by a physician orother licensed provider within the scope ofhis/her practice.• Beneficiaries must receive services fromproviders that are licensed as communitymental health treatment team providersTargeted Case ManagementService Description Coverage RequirementsTargeted CaseManagement forChildrenServices to assist qualifiedbeneficiaries to gain access tomedical, educational rehabilitativeand social services, includinglocating, coordinating andmonitoring services.• To qualify for services beneficiaries must- be under age 21- have a severe mental illness or emotionaldisturbance• Services may only be delivered as part of anactive treatment plan• Beneficiaries cannot receive services that areintegral part of another medical assistanceprogram or inpatient programInformation as reported by state Medicaid and SCHIP agencies Pennsylvania page 5 of 7

PennsylvaniaData as of July 2003Targeted Case ManagementService Description Coverage RequirementsTargeted CaseManagement forAdults with mentalillnessServices to assist qualifiedbeneficiaries in gaining access toneeded services, including• linking with services;• monitoring of service delivery;• gaining access to services;• assessment and serviceplanning;• problem resolution;• informal support networkbuilding; and• use of community resources• To qualify for services beneficiaries must- be age 21 or older- have severe and persistent mental illness.• Services may only be delivered as part of anactive treatment plan• Beneficiaries cannot receive services that areintegral part of another medical assistanceprogram or inpatient programSCHIP Medicaid Expansion ProgramPennsylvania does not operatean SCHIP Medicaid Expansion Program.Separate SCHIP ProgramWho is Eligible for the Separate SCHIP Program?The SCHIP program covers children age 0-18 with family incomes up to 200% FPL.What Mental Health/Substance Abuse Services are Covered by theSeparate SCHIP Program?Benefits in Separate SCHIP programs must be actuarially equivalent to a benchmark selected by the State,among federally established options. Pennsylvania was one of three states specifically allowed to use thesame benefit package as an existing, state-sponsored, children’s coverage program—the PennsylvaniaChildren's Health Insurance Program (PA CHIP) which was implemented in May 1993. Coverage specificsfor mental health and substance abuse services that would meet that benchmark are identified here.InpatientService Description Coverage RequirementsMentalHealth/SubstanceAbuseSubstance AbuseResidentialIncludes mental health servicesprovided in psychiatric or generalhospital and partialhospitalizationParticipants may receive no more than a combinedtotal of 90 day per year of inpatient hospital services,including mental health and substance abuseadmissions.Detoxification limited to seven days per year, with alifetime maximum of four inpatient admissions30 days per year; lifetime maximum of 90 days.Information as reported by state Medicaid and SCHIP agencies Pennsylvania page 6 of 7

PennsylvaniaData as of July 2003Outpatient (Office Visits)Service Description Coverage RequirementsMentalHealth/SubstanceAbuseOutpatient mental health andsubstance abuse including opioidtreatments such as LAAM.1. Participants may receive no more than a combinedtotal of 50 outpatient visits per year of mental healthand/or substance abuse services.2. Up to 50 visits/outpatient mental health services canbe exchanged for inpatient hospital days.Substance Abuse30 full sessions visits per year; lifetime maximum of120 days.Information as reported by state Medicaid and SCHIP agencies Pennsylvania page 7 of 7