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© Otsuka America Pharmaceutical, Inc., Rockville, MD
The PsychU Guide To The Arizona Mental Health
System
MRC2.CORP.D.00042
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requirements governing health care services, and that treatment decisions are made consistent with the applicable standards of care.
Except as otherwise indicated, the information provided is accurate to the best of Otsuka’s knowledge as of December 2014.
MRC2.CORP.D.00042
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1. Health Care Coverage Map Of Arizona2. Population Distribution By Payer:
National vs. State 3. Largest Health Plans In Arizona By
Enrollment4. Largest Health Plans in Arizona By SMI
Enrollment5. Arizona Medicaid System Overview6. Arizona Medicaid Governance7. Arizona Medicaid System Benefits8. Arizona Medicaid Financing & Service
Delivery9. Arizona Medicaid Fee-For-Service10. Arizona Medicaid Managed Care11. Arizona Medicaid Medical & Health
Home Initiatives
12. Arizona State Mental Health & Addiction Treatment Department Organization Chart
13. Arizona State Mental Health & Addiction Treatment Department Governance
14. Arizona State Psychiatric Institutions15. Arizona Accountable Care Organizations
(ACOs)16. Arizona Health Care Reform Initiatives17. Arizona Health Insurance Marketplace
Plans18. Arizona Essential Health Benefit
Benchmark Plan
3
The PsychU Guide To Mental Health Payers In Arizona - Contents
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Health Care Coverage Map Of Arizona
4
The information provided by PsychU is intended for your educational benefit only. It is not intended as, nor is it a substitute for medical care or advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare professional.
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16%
13%
2%
49%
2%2%
9%
ArizonaMedicaid 16%Medicare 13%Medicaid Expansion 7%Dual Eligibles 2%Commercial 49%Health Insurance Marketplace 2%Other Public 2%
14%
14%
5%
2%53%
3%1%8%
NationalMedicaid 14%Medicare 14%Medicaid Expansion 5%Dual Eligibles 2%Commercial 53%Health Insurance Marketplace 3%Other Public 1%
5
2. Population Distribution By Payer: National vs. State
*Based on 2011-2012 data
Total Population: 6,578,900 Total Population: 310,917,000
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Basic StandardStarter Premium
3. Largest Health Plans In Arizona By Enrollment
6
*Based on enrollment as of fourth quarter 2013
Plan Name Plan Type Enrollment*Blue Cross Blue Shield of Arizona, Inc. Commercial 1,117,656
Medicare Fee-For-Service (FFS) Medicare 574,895
UnitedHealth Commercial Administrative Services Only (ASO)
341,512
United Healthcare Medicaid 336,119
Mercy Care Plan Medicaid 298,196
UnitedHealthcare Insurance Company Commercial 218,344
Cigna Commercial ASO 216,098
Aetna Commercial ASO 199,863
Health Choice Medicaid 198,680
Medicaid FFS Medicaid 175,134
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Basic StandardStarter Premium
7
4. Largest Health Plans in Arizona By SMI Enrollment
*Based on enrollment as of fourth quarter 2013
Plan Name Plan Type Enrollment* Estimated SMI Enrollment
Medicare FFS Medicare 574,895 50,016
United Healthcare Medicaid 336,119 16,806
Mercy Care Plan Medicaid 298,196 14,910
Health Choice Medicaid 198,680 9,934
Medicaid FFS Medicaid 175,134 8,757
PacifiCare of Arizona, Inc. Medicare 92,682 8,063
Blue Cross Blue Shield of Arizona, Inc.
Commercial 1,117,656 7,824
University Family Care Medicaid 127,524 6,376
Care 1st Arizona Medicaid 101,472 5,074
Health Net Access Medicaid 79,380 3,969
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8
5. Arizona Medicaid System OverviewMedicaid System GovernanceState Medicaid Director Thomas J. Betlach
State Medicaid Director reports to Janet K. Brewer, Governor
Medicaid Financial Delivery SystemState participating in Medicaid expansion? Yes
Is managed care mandatory for populations with SMI? Yes
Is managed care mandatory for dual eligibles? Yes
Total Medicaid population distribution 11% in FFS89% in Managed Care
Medicaid beneficiaries with SMI: Primary service system Because the SMI population must enroll in managed care unless they meet one of the FFS qualifications, the majority of the SMI population is served by managed care.
Medicaid Financing & Risk Arrangements: Behavioral HealthTraditional Behavioral Health Services • Acute MCOs and Arizona Long-Term Care Services (ALTCS): Included in the MCO’s
capitation rate• Maricopa County SMI Population: Included in Mercy Maricopa’s capitation rate
Specialty Behavioral Health Services • Acute MCOs and ALTCS: Covered by the Regional Behavioral Health Authorities (RBHAs) and excluded from the MCO’s capitation rate.
• Maricopa County SMI Population: Included in Mercy Maricopa’s capitation rate
Pharmaceuticals • Acute MCOs and ALTCS: Antipsychotics covered by the RBHAs, all other pharmacy included in the MCO’s capitation rate
• Maricopa County SMI Population: Included in Mercy Maricopa’s capitation rate
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9
6. Arizona Medicaid Governance
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10
6. Arizona Medicaid Governance
Name Position Department Thomas J. Betlach
Director Arizona Health Care Cost Containment System (AHCCCS)
Beth Kohler Lazare
Deputy Director AHCCCS
Sara Salek, MD Chief Medical Officer AHCCCS
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11
7. Arizona Medicaid System BenefitsFederally Mandated Services
1. Inpatient hospital services other than services in an institution for mental disease
2. Outpatient hospital services 3. Rural Health Clinic services4. Federally Qualified Health Center services5. Laboratory and X-ray services6. Nursing facilities for individuals 21 and over7. Early and Periodic Screening and Diagnosis and
Treatment (EPSDT)8. Family planning services and supplies for
individuals of child-bearing age9. Physician services10. Medical and surgical services of a dentist11. Home health services12. Nurse midwife services13. Nurse practitioner services14. Pregnancy services, including tobacco cessation
programs15. Free standing birth centers16. Non-emergency transportation to medical care
Arizona’s Optional Services
1. Other labs and X-ray services2. Private duty nursing services3. Clinic services4. Dental services5. Physical therapy, occupational therapy, and related
services6. Services for individuals with speech hearing and
language disorders7. Prescribed drugs8. Prosthetic devices and eyeglasses9. Diagnostic, screening services, and preventive
services10. Hospice care11. Respiratory care services12. Personal care services13. Behavioral health14. Services of nurses in religious non-medical health
care institutions 15. Case management and tuberculosis related services16. Inpatient psychiatric facility services for individuals
under 21 years of age17. Services for individuals over age 65 in an institution of
mental disease (IMD)
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12
8. Arizona Medicaid Financing & Service Delivery
Medicaid System CharacteristicsCharacteristics Medicaid Fee-For-Service (FFS) Medicaid Managed Care (MC)
June 2014 Enrollment 175,134 1,281,156
SMI Enrollment Because the SMI population must enroll in managed care unless they meet one of the FFS qualifications, the majority of the SMI population is served by managed care.
Management AHCCCS • Acute Care: Eight acute MCOs• ALTCS: Three long-term and
acute care MCOs• Behavioral Health: Six RBHAs
Payment Model Fee-for-service Capitated rate (all)
Geographic Service Area Statewide Statewide operating on a regional basis (all)
Total Medicaid 1,456,990 | Total Medicaid With SMI 29,000
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13
9. Arizona Medicaid Fee-For-Service
Optional Enrollment In FFSThe only population eligible to enroll in the FFS program is the American Indian/Alaskan native population.
• The FFS program for American Indians is called the American Indian Health Program (AIHP). They are able to receive service from any AHCCCS provider, Indian Health Service (IHS) facility, or a tribally operated (638) facility on a fee-for-service basis.
• American Indians are able to switch back and forth from a AHCCCS managed care plan to AIHP at any time.
Fee-for-service enrollment as of September 2014 was 175,134.
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Arizona Medicaid Fee-For-Service
14
1. Behavioral management2. Case management3. Emergency behavioral health care4. Evaluation5. Therapeutic residential support (in-home, excludes room and board)6. Inpatient hospital7. Inpatient psychiatric facilities8. Psychotropic medications9. Medication adjustment and monitoring10. Methadone11. Partial care12. Individual, group, and family professional services13. Psychosocial rehabilitation14. Respite15. Screening
American Indians may elect to receive services from a Tribal/Regional Behavioral Health Authority (described in B.7.) or from a 638 or IHS facility.
FFS Mental Health Benefits:
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10. Arizona Medicaid Managed Care
15
• Managed care enrollment as of September 2014 was 1,281,856.
• Arizona has two Medicaid programs to serve Medicaid enrollees: – Acute Managed Care Organizations (MCOs): Provide acute care services
through eight prepaid, capitated MCOs. MCOs are available by geographic service area (GSA), which refers to either one specific county or a grouping of counties. Enrollees in the acute MCO program can choose any plan available in their GSA.
– Arizona Long-Term Care System (ALTCS): Provide acute care and home and community based services (HCBS) for those who are 65 and older, blind, disabled, and have a medical need for LTSS. Services are provided through three prepaid capitated MCOs that are available by GSA. Enrollees in the ALTCS program only have a choice of MCO, if there is more than one ALTCS MCO in their GSA.
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Arizona Medicaid Managed Care Program: Health Plans by GSA
16
GSA Counties Acute MCOs ALTCS MCOs2 La Paz, Yuma UnitedHealthcare, University Family
CareUnitedHealthcare LTC
4 Mohave, Coconino, Navajo, Apache
Health Choice Arizona, UnitedHealthcare
UnitedHealthcare LTC
6 Yavapai UnitedHealthcare, University Family Care
UnitedHealthcare LTC
8 Gila, Pinal Health Choice Arizona, University Family Care
Bridgeway Health Solutions
10 Pima, Santa Cruz Mercy Care Plan, UnitedHealthcare, Health Choice Arizona, Care 1st Arizona, University Family Care
Mercy Care Plan LTC,UnitedHealthcare LTC,
12 Maricopa Care 1st Arizona, Health Net Access, Health Choice Arizona, Maricopa Health Plan, Mercy Care Plan, Phoenix Health Plan, UnitedHealthcare
Mercy Care Plan-LTC, Bridgeway Health Solutions, UnitedHealthcare LTC
14 Graham, Cochise,Greenlee
UnitedHealthcare, University Family Care
Bridgeway Health Solutions
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Arizona Medicaid Managed Care
17
• Acute MCOs and ALTCS: Behavioral health services are not provided by the health plan, but are the responsibility of prepaid inpatient health plans (PIHPs), known as Tribal/Regional Behavioral Health Authorities (T/RBHA). – Primary care physicians are able to provide medication
management for anxiety, depression, and attention deficit hyperactivity disorder (ADHD).
• The RBHAs are divided into six GSAs that are similar to, but not the same as, the acute care GSAs.
• American Indians in managed care can either receive services through the RBHA or TRBHA.
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Arizona Medicaid Managed Care: Behavioral Health Benefits
18
• Behavioral management• Case management• Emergency behavioral health care• Evaluation• Therapeutic residential support (in-home, excludes room and board)• Inpatient hospital• Inpatient psychiatric facilities• Psychotropic medications• Medication adjustment and monitoring• Methadone and IAAM • Partial care• Individual, group, and family professional services• Psychosocial rehabilitation• Respite• Screening
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Arizona Medicaid Managed Care Program: RHBAs By County
19
GSA Counties RBHA
1 Mohave, Coconino, Navajo, Apache, Yavapai
Northern Arizona Regional Behavioral Health Authority (NARBHA)
2 La Paz, Yuma Cenpatico 23 Greenlee, Graham, Cochise,
Santa CruzCenpatico 3
4 Gila, Pinal Cenpatico 45 Pima Community Partnership of Southern Arizona6 Maricopa Mercy Maricopa Integrated TRBHAs (serves members located on the Tribe’s reservation) Gila River CommunityNavajo NationPascua Yaqui TribeWhite Mountain Apache Tribe of Arizona Colorado River Tribe- only provides state subsidized services
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Arizona Medicaid Managed Care: SMI Population
20
• Individuals with SMI are not exempt from enrolling in managed care unless they also meet one of the fee-for-service criteria.
• If an individual resides in Maricopa County and has SMI, they will receive behavioral and acute services through an integrated specialty RBHA. See slide 32 for more information.
• The integrated specialty RBHA, Mercy Maricopa, began operating in 2014. Previously the contract was held by Magellan, which operated as a standard RBHA.
• Medicaid expansion population, if medically frail, must be offered the full array of State Plan benefits. Medically frail individuals include adults with serious mental illness and chronic substance abuse disorders.
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Arizona Medicaid Managed Care: Plans By County
21
Mercy Maricopa Integrated Care 2014TargetPopulation
Medicaid and dual eligible enrollees with SMI: approximately 18,000 individuals
Care Delivery Model
Services provided through the health homes model
Care Coordination ServiceRequirements
• Co-located services in existing SMI clinics, called Whole Health Clinics • Primary Care Physician (PCPs) act as patient centered medical homes or virtual health homes
for those who choose to not receive services at whole health clinic • Member centered goals and recovery model• Development of an Individual Recovery Plan • Enhanced care coordination
Payment Model Per member per month (PMPM) capitated rate: $2,341.37
Benefits • Physical health benefits• Behavioral health benefits, plus supported housing, supported employment, Assertive
Community Treatment (ACT), and consumer operated programs
Practice Performance & Improvement
• State specified minimum standards and goals, including inpatient utilization, hospitalreadmissions, emergency department utilization, comprehensive diabetes management, and access to a PCP
• Performance improvement projects
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• Arizona applied for and received funding through a 2011 planning grant to determine the feasibility of health homes for populations with SMI.
• As of October 2014, health homes’ functions are being provided by behavioral health organizations to meet care coordination requirements. There is no official SPA or legal entity requiring them to create health homes.
11. Arizona Medicaid Medical & Health Home Initiatives
22
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12. Arizona State Mental Health & Addiction Treatment Department Organization Chart
2323
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13. Arizona State Mental Health & Addiction Treatment Department Governance
24
Name Position DepartmentWill Humble Director Arizona Department Cory Nelson Deputy Director ADPH Division of Behavioral Health
ServicesPaul Galdys Assistant Director Operations and DevelopmentAaron Bowen Assistant Director Quality and IntegrationMargery Ault Assistant Director Compliance and Consumer RightsSteven F. Dingle, M.D.
Chief Medical Officer Behavioral Health Services
Cynthia Layne Chief Financial Officer Bureau of Financial Operations
Donna Noriega CEO Arizona State Hospital
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Basic StandardStarter Premium
14. Arizona State Psychiatric Institutions
25
Institution Name Location Beds FY 2013 Admissions
FY 2013Discharges
2013Average Daily Census
Arizona State Hospital
Phoenix 260 64 55 237
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15. Arizona Accountable Care Organizations (ACOs)
26
Medicare Shared Savings Program Pioneer ACO1. Arizona Care Network, LLC 2. Arizona Priority Care Plus3. ASPA-Connected4. GPIPA ACO5. John C. Lincoln Accountable Care Organization,
LLC6. North Central Arizona Accountable Care, LLC7. Premier Care Network, LLC8. Scottsdale Health Partners9. Southern Arizona Accountable Care Organization,
LLC10. Yavapai Accountable Care11. Yuma Connected Community
1. Banner Health Network (Phoenix)
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Arizona Accountable Care Organizations (ACOs)
27
Commercial ACOsACO Commercial InsurerBanner Health Network Aetna
Banner Health Network Cigna
Banner Health Network ACO Humana
Cigna Medical Group (CMG) of Arizona Collaborative Accountable Care (CAC)
Cigna
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16. Arizona Health Care Reform Initiatives
2828
Medicaid Expansion
Choose to participate in expansion?
Yes
Medicaid Eligibility Income Limit for Childless Adults
133% of FPLNote: The PPACA requires that 5% of income be disregarded with determining eligibility
SpecificLegislation Enacted
House Bill 2010
Health Insurance MarketplaceType of Marketplace
Federal
IndividualEnrollment Contact
www.healthcare.gov
1-800-318-2596
Small BusinessEnrollment Contact
www.healthcare.gov/small-businesses
1-800-706-7893
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17. Arizona Health Insurance Marketplace Plans
2929
Individual Market• Health Net Life Insurance Company• Blue Cross Blue Shield of Arizona• Aetna• Cigna Healthcare• Health Choice Insurance Co. • Health Net of Arizona• Humana Health Plan• Meritus Health Partners • Meritus Mutual Health Partners• University of Arizona Health Plans-
University Healthcare Marketplace
Small Group Market• Health Net Life Insurance Company• Blue Cross Blue Shield of Arizona• Health Net of Arizona• Meritus Health Partners • Meritus Mutual Health Partners
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18. Arizona Essential Health Benefit Benchmark Plan
30
Plan Type Plan from largest state employee plan, Exclusive Provider Organization
Issuer Name State of Arizona Self-Insured Plan, administered by United Healthcare
Plan Name Arizona Benefit Options EPO Plan, administered by United Healthcare
Supplemented Categories (Supplementary Plan Type)
• Pediatric Oral (FEDVIP) • Pediatric Vision (FEDVIP)
Habilitative Services Defined by State
No; when the benchmark plan and the state do not define habilitativeservices the benefit is covered using the federal definition; provides parity that are similar in scope, amount, and duration to benefits covered for rehabilitative services.
Biologically Based Mental Illness Covered the same as any other medical benefit as described in the 2008 Mental Health Parity and Addiction Equity Act
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Arizona Essential Health Benefit Benchmark Plan
31
Benefit Limit on Service Exclusions (apply to all benefits)
Non
-Bio
logi
cally
Bas
ed M
enta
l Illn
ess
Mental/Behavioral Health Outpatient Services
No None
Mental/Behavioral Health Inpatient Services
No
Substance Abuse Disorder Outpatient Services
90 days per year
Substance Abuse Disorder InpatientServices
No
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1. Arizona Health Care Coverage Map1. Arizona Health Care Cost Containment System. Health Plan Contact Information. Retrieved September 14, 2014 from
https://azweb.statemedicaid.us/HealthPlanLinksNet/HPLinks.aspx2. The Henry J. Kaiser Foundation. (2014, April 19). State Health Facts: Health Reform Indicators. Retrieved September 14, 2014 from
http://kff.org/state-category/health-reform/3. Thierer, C. (2014, June 20). QHP Landscape Individual Market Medical. Retrieved July 1, 2014 from
https://data.healthcare.gov/dataset/QHP-Landscape-Individual-Market-Medical/b8in-sz6k4. Thierer, C. (2014, June 20). QHP Landscape SHOP Market Medical. Retrieved July 1, 2014 from https://data.healthcare.gov/dataset/QHP-
Landscape-SHOP-Market-Medical/ss3e-3mza
2. Arizona Population Distribution By Payer: National vs. State 1. Arizona Health Care Cost Containment System. (2014, March 1). Arizona Health Care Cost Containment System- Dual Eligible Enrollment
By County. Retrieved September 14, 2014 from http://www.azahcccs.gov/reporting/Downloads/Integration/ByCounty.pdf2. Centers for Medicare and Medicare Services. (2013, February). Data Analysis Brief Medicare-Medicaid Dual Enrollment from 2006 through
2011. Retrieved September, 14 2014 from http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/Dual_Enrollment_2006-2011_Final_Document.pdf
3. The Henry J. Kaiser Foundation. (2012). State Health Facts: Health Insurance Coverage of the Total Population. Retrieved September 14, 2014 from http://kff.org/other/state-indicator/total-population/
4. The Henry J. Kaiser Foundation. (2014, April 19). State Health Facts: Health Reform Indicators. Retrieved September 14, 2014 from http://kff.org/state-category/health-reform/
5. The Kaiser Foundation definition for Medicaid includes dual eligible individuals. To avoid double counting, the number of dual eligibles was subtracted from the total number of Medicaid enrollees.
6. Other Public refers to military and Veteran’s Administration coverage.
Sources
32
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The information provided by PsychU is intended for your educational benefit only. It is not intended as, nor is it a substitute for medical care or advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare professional.
3. Largest Health Plans In Arizona By Enrollment1. Centers for Medicare and Medicaid Services. (2012). Medicare Geographic Variation State/County Table- All Beneficiaries. Retrieved
September 14, 2014 from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Geographic-Variation/GV_PUF.html
2. Health Plans USA. (2013). Subscription Database. Available from http://www.markfarrah.com/products/health-plans-usa.aspx3. Arizona Health Care Cost Containment System. (2014, September). AHCCCS Population By Health Care Contractor. Retrieved September
14, 2014 from http://www.azahcccs.gov/reporting/Downloads/PopulationStatistics/2014/Sep/Members_by_Contractor_Report.pdf
4. Largest Health Plans in Arizona By SMI Enrollment1. Centers for Medicare and Medicaid Services. (2012). Medicare Geographic Variation State/County Table- All Beneficiaries. Retrieved
September 14, 2014 from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Geographic-Variation/GV_PUF.html
2. Health Plans USA. (2013). Subscription Database. Available from http://www.markfarrah.com/products/health-plans-usa.aspx3. Arizona Health Care Cost Containment System. (2014, September). AHCCCS Population By Health Care Contractor. Retrieved September
14, 2014 from http://www.azahcccs.gov/reporting/Downloads/PopulationStatistics/2014/Sep/Members_by_Contractor_Report.pdf
5. Arizona Medicaid System Overview• Compiled from information found throughout the profile.
6. Arizona Medicaid Governance1. Arizona Health Care Cost Containment System. (2014, September 2). Arizona Health Care Cost Containment System Agency
Administration and Management. Retrieved September 14, 2014 from http://www.azahcccs.gov/shared/Downloads/AHCCCSorgchart.pdf
7. Arizona Medicaid System Benefits1. Centers for Medicare and Medicaid Services. Medicaid Benefits. Retrieved September 14, 2014 from http://www.medicaid.gov/Medicaid-
CHIP-Program-Information/By-Topics/Benefits/Medicaid-Benefits.html2. Arizona Health Care Cost Containment System. (2013, April). Arizona Health Care Cost Containment System. Retrieved September 14,
2014 from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/az/Health-Care-Cost-Containment-System/az-hccc-stc-10012011-09302016-amended-042013.pdf
Sources
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8. Arizona Medicaid Financing & Service Delivery1. Arizona Health Care Cost Containment System. (2014, September). AHCCCS Population By Health Care Contractor. Retrieved September
14, 2014 from http://www.azahcccs.gov/reporting/Downloads/PopulationStatistics/2014/Sep/Members_by_Contractor_Report.pdf2. Arizona Health Care Cost Containment System. (2013, April). Arizona Health Care Cost Containment System. Retrieved September 14,
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The information provided by PsychU is intended for your educational benefit only. It is not intended as, nor is it a substitute for medical care or advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare professional.
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