When a county agrees to opt into participation in the DMC-ODS, it does so as a managed care organization known as Prepaid Inpatient Hospital Plan (PIHP). The county as such agrees to comply with all federal managed care plan conditions and requirements, including very defined standards and requirements related to the protection of the beneficiaries. Under the administration of the Substance Abuse Prevention and Treatment Block Grant services, SUD delivery system prioritizes standards related to waiting list fairness and a great deal of diversity in service access. These standards and practices change and will develop under the DMC-ODS in an environment of service entitlement, beneficiary rights, and care coordination.
The DMC-ODS county or PIHP assures beneficiary protections by 1) assuring that the delivery network is adequate; 2) the quality of care meets acceptable standards, and 3) the enrollees or beneficiaries understand the plan and how to access services and have a way of registering complaints.
On April 25, 2016, the Centers for Medicare & Medicaid Services (CMS) issued the Medicaid and CHIP Managed Care Final Rule, the first major update to Medicaid and CHIP managed care regulations in more than a decade. The Final Rule modernizes how states purchase managed care for beneficiaries and strengthens the consumer experience and key consumer protections. The Final Rule now applies to all Specialty Mental Health services statewide, as well as counties opting into the 1115 Waiver substance use disorder organized delivery system.
At the most basic level, counties must provide enrollment notices and informational and instructional materials that are easily understood in language and format, including alternative formats to ensure comprehension and understanding of the requirements and benefits of the plan (42 CFR 438.10). The development of the beneficiary brochure has taken a considerable effort. Upon enrollment of the beneficiaries that includes a list of providers and is updated regularly. Santa Clara County, Behavioral Health Services Department has completed their Beneficiary Handbook with all required legal reviews. Attached is a copy for reference or support in the development of county plan specific materials.
One final note: There are documented limits to the effectiveness of written materials in enrollment and engagement into managed care. As we go forward and the system matures, it will be important to look for examples of approaches that will engage vulnerable populations into these programs including direct contact, navigators, and support from the network providers.