Mental Health Benefits in the Duals Demonstration

Inpatient Services* Primary Financial Responsibility

Patient meets criteria Patient does NOT meet Type of Service Primary for county MHP criteria for county MHP Payer specialty mental specialty mental health health services services

Medicare Demonstration Health Demonstration Health Facility Charge Subject to coverage Plan Plan Psychiatric limitations Inpatient Psychiatric Medicare Demonstration Health Demonstration Health Hospital** Professional Subject to coverage Plan Plan General Acute Services*** limitations Hospital Medical, Pharmacy, Medicare Demonstration Health Demonstration Health Ancillary Professional Subject to coverage Plan Plan Services limitations Facility Charges Subject to the federal Patient ages 22- 64 Not a Medi- IMD exclusion for admitted to mental Cal or Medicaid NA health treatment Medicare Institutions reimbursement for Mental facilities of 16 beds benefit purposes Diseases or more (Mental Health Facility Charges Demonstration Health Rehab Center patient ages 65 or Medicare NA Plan or Skilled older Nursing Psychiatric Subject to the Medicaid Demonstration Health Medicare Facility)*** professional services IMD exclusion Plan Pharmacy, ancillary, Subject to the Medicaid Demonstration Health and medical Medicare IMD exclusion Plan professional services Demonstration Health Demonstration Health Facility Charges Medicare Plan Plan Psychiatric Demonstration Health Demonstration Health Professional Medicare Plan Plan Emergency Charges**** Department Pharmacy, ancillary, and medical Demonstration Health Demonstration Health Medicare professional services Plan Plan

DDHP= Duals Demonstration Health Plan MHP = Mental Health Plan

*As the payer of last resort, county Mental Health Plans (MHPs) are responsible for the balance of inpatient psychiatric care that is not covered by Medicare for those beneficiaries meeting the medical necessity criteria for specialty mental health services. **Medi-Cal and the County MHP is responsible for local hospital administrative days, which are days that a patient's stay in the hospital is beyond the need for acute care and there is a lack of nursing facility beds available. ***Federal law prohibits Medicare or Medi-Cal payment beneficiaries age 22 to 64 placed in IMDs. This is known as the “IMD exclusion” is described in DMH Letters 02-06 and 10-02. ****Medicare covers mental health services provided by a doctor, clinical psychologist, clinical social worker, clinical nurse specialist, or physician assistant in an office setting, clinic, or hospital outpatient department.

Last Updated 8/13/12 1 Mental Health Benefits in the Duals Demonstration

Outpatient Services Primary Financial Responsibility Patient does NOT Patient meets criteria for criteria for MHP Type of Service Primary Payer MHP specialty mental specialty mental health services health services Demonstration Health Pharmacy Medicare Demonstration Health Plan Plan Partial hospitalization / Intensive Demonstration Health Medicare Demonstration Health Plan Outpatient Plan Outpatient services within the scope Demonstration Health Medicare NA of primary care Plan Psychiatric services: (including medication management, assessment, individual and group therapy delivered by a Demonstration Health doctor, clinical psychologist, clinical social Medicare Demonstration Health Plan worker, clinical nurse specialist, or Plan physician assistant in an office, clinic, or hospital outpatient department) Demonstration Health Psychiatric testing/ assessment Medicare Demonstration Health Plan Plan Specialty Mental Health Services (1915b waiver services) Assessment, County MHP/DDHP individual and Depends on whether Mental health services (individual and group therapy NA group therapy, assessment, collateral, plan services meet Medicare can be BOTH development) provider and location Medicare and criteria Medi-Cal Medication support services (prescribing, administering, dispensing and monitoring drug interactions and Medi-Cal and County MHP/DDHP Medicare when Depends on whether contraindications of psychiatric NA medications, including the evaluation of delivered by a services meet Medicare need, clinical effectiveness and side covered provider and location effects; obtaining informed consent; practitioner criteria education; collateral and plan development) Medi-Cal County MHP/DDHP (Similar to Depends on whether partial Day treatment intensive services meet Medicare NA hospitalization, provider and location a Medicare criteria benefit ) Day rehabilitation Medi-Cal County MHP NA Crisis intervention Medi-Cal County MHP NA PES Crisis stabilization Medi-Cal County MHP NA

Adult Residential treatment services Medi-Cal County MHP NA Crisis residential treatment services Medi-Cal County MHP NA Targeted Case Management Medi-Cal County MHP NA

Last Updated 8/13/12 2