Care management    

At an integrated health home (IHH), people can get these services:  

• Medical and annual physician exams  

• Treatment  

• Medicine (injections)  

• Basic lab tests   

• Other basic primary care services   

An IHH can also coordinate care for people in need of specialty health care services, like home health or dialysis.  

You’ll want to have comprehensive care in one electronic health record. Primary care and behavioral health teams provide complete, whole-person services.    

Case management

Some DCS CHP members get a case manager. They work with you, your family, health care decision maker and PCP to help decide which services best meet your needs. Your behavioral health home provides these services.

Discharge planning  

This is the process of preparing to move from one type of care to another. You might be moving from a hospital to your home. Or from a hospital to a long-term care facility.   

Planning helps ensure that you keep getting the care you need. You’ll understand what to do, like: 

• What appointments to make  

• How to take your medicine 

Planning also helps lower the chance of having problems or returning to a hospital or other facility.  

Peer and family support  

You can get help from a peer support worker. This is someone with the lived experience of recovery from a mental health condition, substance use disorder (SUD) or both. They are certified to help you. And can guide you through the behavioral health care system.  

Primary care services  

At an integrated health home (IHH), people can get these services:  

• Medical and annual physician exams  

• Treatment  

• Medicine (injections)  

• Basic lab tests   

• Other basic primary care services   

An IHH can also coordinate care for people in need of specialty health care services, like home health or dialysis.     

You’ll want to have comprehensive care in one electronic health record. Primary care and behavioral health teams provide complete, whole-person services.    

Residential behavioral health services 

Residential behavioral health settings include: 

• Behavioral Health Inpatient Facilities (BHIF) 

• Behavioral Health Residential Facilities (BHRF) 

• Therapeutic Foster Care (TFC) 

Residential treatment for SUDs 

Services can include residential settings for behavioral health conditions. This structured setting provides counseling and teaches independent living skills.  

Residential behavioral health settings include: 

• Behavioral Health Inpatient Facilities (BHIF) 

• Behavioral Health Residential Facilities (BHRF) 

• Therapeutic Foster Care (TFC) 

Respite care 

Respite care is for caregivers of children and youth. It means taking time for yourself. The hours are based on your need. It may be on a short-term basis, like a few hours during the day. Or longer periods with overnight stays.  

The maximum number of total hours is 600 each benefit year (October 1 to September 30).   

Treatment for opioid use disorders and SUDs 

Medication-assisted treatment (MAT) is for opioid use disorders and SUDs. Providers use it along with counseling or behavioral therapies. You can get MAT from your opioid treatment provider. They can coordinate care with your other providers. 

BHRF care and services:

• Are based on a per diem rate (24-hour day)

• Need prior and continued authorization 

• Don’t include room and board 

• Aren’t locked facilities

BHRF is a 24-hour per day treatment.

This level of care is for members who need supervision at all times. BHRF assists with basic independent living skills, like: 

• Bathing 

• Cooking 

• Doing laundry 

AHCCCS AMPM 320V (PDF) is the name of the clinical criteria providers use to see if people may benefit from this level of care. 

We process all BHRF applications as expedited requests. We also follow ACOM Policy 414 for expedited request time frames and requirements. 

Upon intake to and discharge from the BHRF, our outpatient and BHRF providers send notice to the:

• Primary care physician (PCP)

• Behavioral health provider

• Agency

• Tribal Regional Behavioral Health Authority (TRBHA) 

CRITERIA FOR ADMISSION, CONTINUED STAY AND DISCHARGE READINESS 

We have adopted the medical necessity criteria of AHCCCS, which includes:

• Minimum elements defined in AMPM 320-V for admission

• Expected treatment outcomes

• Exclusionary criteria

• Continued stay criteria

Admission, Assessment and Treatment Plan Expectations 

BHRF Providers rendering services shall follow the below outlined admission, assessment, and treatment planning requirements. 

1. Except as provided in subsection R9-10-707(A)(9), a behavioral health assessment for a member is completed before treatment is initiated and within 48 hours of admission. 
2. The CFT/ART/ is included in the development of the Treatment Plan within 48 hours of admission for members enrolled with Mercy Care. 
3. BHRF documentation shall reflect:
   
   
   • All treatment services provided to the member, 
   • Each activity shall be documented in a separate, individualized medical record, including the date, time, and professional conducting treatment activity, 
   • Which treatment plan goals are being achieved, 
   • Progress towards desired treatment goal, and 
   • Frequency, length and type of each treatment service or session. 
4. All BHRFs shall coordinate care with the outpatient treatment team throughout the admission, assessment, treatment, and discharge process.
5. The Treatment Plan connects back to the member’s comprehensive Service Plan for members enrolled with Mercy Care.
6. A comprehensive discharge plan is created during the development of the initial Treatment Plan and is reviewed and/or updated at each review thereafter. The discharge plan documents the following:
    
   • Clinical status for discharge, 
   • Member/guardian/designated representative and, CFT/ART , ALTCS understands follow-up treatment, crisis and safety plan, and 
   • Coordination of care and transition planning are in process (e.g. reconciliation of medications, applications for lower level of care submitted, follow-up appointments made, identification of wrap around supports and potential providers). 
7. The BHRF staff and the CFT/ART meet to review and modify the Treatment Plan at least once a month. 
8. A Treatment Plan may be completed by a BHP, or by a BHT with oversight and signature by a BHP within 24 hours. 
9. The provider has a system to document and report on timeliness of BHP signature/review when the Treatment Plan is completed by a BHT. 
10. The provider has a process to actively engage family/health care decision maker/designated representative in the treatment planning process as appropriate. 
11. The provider’s clinical practices, as applicable to services offered and population served, shall demonstrate adherence to best practices for treating specialized service needs, including but not limited to: 
    
    
    • Cognitive/intellectual disability, 
    • Cognitive disability with comorbid Behavioral Health Condition(s), 
    • Older adults, and Co-Occurring disorders (substance use and Behavioral Health Condition(s), or 
    • Comorbid physical and Behavioral Health Condition(s). 
12. Services deemed medically necessary through the assessment and/or CFT/ART/ALTCS which are not offered at the BHRF, shall be documented in the Service Plan and documentation includes a description of the need, identified goals and identified provider who will be meeting the need. The following services shall be made available and provided by the BHRF and cannot be billed separately unless otherwise noted below: 
    
    
    • Counseling and Therapy (group or individual): Behavioral Health Counseling and Therapy may not be billed on the same day as BHRF services unless specialized behavioral health counseling and therapy have been identified in the Service Plan as a specific member need that cannot otherwise be met as required within the BHRF setting, 
    • Skills Training and Development:
       
      • Independent Living Skills (e.g. self-care, household management, budgeting, avoidance of exploitation/safety education and awareness), 
      • Community Reintegration Skill building (e.g. use of public transportation system, understanding community resources and how to use them), and 
      • Social Communication Skills (e.g. conflict and anger management, same/opposite-sex friendships, development of social support networks, recreation). 
    • Behavioral Health Prevention/Promotion Education and Medication Training and Support Services including but not limited to:
       
      • Symptom management (e.g. including identification of early warning signs and crisis planning/use of crisis plan), 
      • Health and wellness education (e.g. benefit of routine medical check-ups, preventive care, communication with the PCP and other health practitioners), 
      • Medication education and self-administration skills, 
      • Relapse prevention, 
      • Psychoeducation Services and Ongoing Support to Maintain Employment Work/Vocational skills, educational needs assessment and skill building, 
      • Treatment for Substance Use Disorder (e.g. substance use counseling, groups), and 
      • Personal Care Services (see additional licensing requirements in A.A.C. R9-10- 702, R9-10-715, R9-10-814). 

BHRF and Medication Assisted Treatment 

Mercy Care expects BHRF Providers to establish policies and procedures to ensure members on MAT are not excluded from admission and are able to receive MAT to ensure compliance with Arizona Opioid Epidemic Act SB 1001, Laws 2018. First Special Session.

There are laws about who can see your behavioral health info with or without permission. People need permission to share info about:

• Substance use treatment 

• Communicable diseases (for example, HIV/AIDS) 

People may not always need permission to share your behavioral health info. One example is sharing info to help arrange and pay for your care. At times, people may share your info with:  

• Physicians and other agencies that health, social, or welfare services  

• Your medical and behavioral health providers  

• Certain state agencies that take part in your care and treatment

• The clinical team who takes part in your care

• The court-ordered treatment team 

At other times, it may be helpful to share your behavioral health info with agencies, like schools. People may need written permission before they share your info.  

Did the Department of Child Safety (DCS) place a child in your care? You may be a foster parent, staff in a group home, other person or agency. You can consent to a child’s evaluation and treatment for: 

• Routine medical treatment 

• Routine dental treatment 

• Behavioral health services   

Here are some examples of behavioral health services. Out-of-home caregivers can consent to these services for children:   

• Assessment and service planning  

• Counseling and therapy  

• Rehabilitation services  

• Medical services  

• Psychiatric evaluation  

• Most medicines for behavioral health treatment  

• Lab services  

• Support services  

• Case management  

• Family support  

• Respite care  

• Rides  

• Crisis services

Find out-of-state facilities contracted to meet the unique needs of members. 

Mental health parity is coverage for mental health and substance use disorder conditions that’s equal to coverage for physical health conditions in insurance plans.

Non-quantitative treatment limitations

Parity applies to the ways health plans manage treatment. That includes practices such as:

• Approving care before it’s provided, or
• Reviewing a provider’s qualifications before they join our network 

These are called non-quantitative treatment limitations (NQTLs). That’s because they may affect the scope or duration of benefits for treatment. And they aren’t stated as a number, unlike a visit or dollar maximum.

Non-quantitative treatment analysis

This analysis explains how our clinical management and network development policies, procedures, and practices comply with the NQTL requirements of the Mental Health Parity and Addiction Equity Act (MHPAEA).