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Benefit Plan Streamlining. Spencer Clark, Patsy Coleman, Starleen Scott Robbins, DeDe Severino, Thelma Hayter. 6/17/14 & 6/19/14. DMHDDSAS. Benefit Plan Streamlining. Purpose:

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benefit plan streamlining

Benefit Plan Streamlining

Spencer Clark, Patsy Coleman,

Starleen Scott Robbins,

DeDe Severino, Thelma Hayter

6/17/14 & 6/19/14


benefit plan streamlining1
Benefit Plan Streamlining


To reduce LME-MCO administrative resources necessary to appropriately pull down DMHDDSAS Federal and State Single Stream funding.

benefit plan streamlining summary
Benefit Plan Streamlining Summary


  • Reduces number of Benefit Plans significantly (from 35 to 10).
  • Does not restrict eligibility for State/Federal services.
  • Utilizes a subset of current Benefit Plans, to reduce the number of Benefit Plan changes necessary (<10% of clients).
benefits cont
Benefits, Cont.
  • UtilizesDSM-5 diagnosticcriteria, ICD-9 diagnosis codes.
  • Allows LME-MCOs flexibility in processing for ensuring eligibility for Benefit Plan and Services.
  • Allows (but does not require) LME-MCOs to automate aspects of eligibility determination for some Benefit Plans.
benefits cont1
Benefits, Cont.
  • Allows for extended end dates for Benefit Plan eligibility (reducing potential for denials due to expiration of eligibility), as long as continued eligibility is ensured through business processes such as authorization.
  • Allows for concurrency between most Benefit Plans.
benefits cont2
Benefits, Cont.
  • Should reduce the volume of denials due to eligibility issues.
new policy
New Policy

The LME-MCO authorization and claims adjudication process must ensure that consumers who receive State/Federal funded services meet the eligibility criteria of the Service Definition or the Benefit Plan, whichever is strictest. The LME-MCO must maintain documentation to support this determination, and make it available to the Division or its agents upon request.

  • Consumer has been previously placed in AMI Benefit Plan, and provider is requesting authorization for outpatient treatment:
    • AMI Benefit Plan criteria is strictest, so as long as the individual meets those criteria (diagnoses and functioning) then LME-MCO may choose to authorize
  • Same consumer, and provider is requesting ACTT:
    • ACTT entrance criteria are strictest and so must be met
lme mco actions necessary
LME-MCO Actions Necessary
  • Develop and/or revise business processes to ensure individuals are eligible for services through UM and claims processing.
  • Train UM staff on revised Benefit Plan Eligibility Criteria, Benefit Plan Diagnosis Array, and Service Array.
  • Ensure providers are utilizing DSM5 by August 1, 2014 and understand the Benefit Plan eligibility criteria.
lme mco actions cont
LME-MCO Actions, Cont.
  • Identify any consumers with Benefit Plans that are being ended. For those who are not also in a continuing Benefit Plan, submit 834s to revise their eligibility, prior to submitting their first claim after July 31st, 2014. (NCTRACKS R2W: BR12008-R0010 or 11)
  • Consider whether to extend the end date on Benefit Plan eligibility for consumers who are unlikely to lose eligibility.

With procedures in place to support the new policy:

      • Individual with I/DD could have an ADSN ending date of 2099
      • Child with CMSED could have a benefit plan end the day before 18th birthday
lme mco actions cont1
LME-MCO Actions, Cont.
  • In NCTRACKS, add the GAP Benefit Plan to Providers who are contracted to perform initial assessments.
benefit plans
Benefit Plans
  • Semi-Automated Benefit Plan Determination: Benefit Plan eligibility may be determined through a semi-automated process for five Benefit Plans:
    • The automated portion of the process should be based on the consumer’s age at the time of service and their primary diagnosis, where primary diagnosis is the main focus of attention or treatment.
benefit plans1
Benefit Plans
  • Individual Benefit Plan Determinations: The remaining Benefit Plans:

must continue to be determined individually, as they require review of several individual and clinical characteristics beyond the primary diagnosis and age group.

benefit plans2
Benefit Plans

GAP = Generic Assessment Payment

  • Effective 7/1/14
  • Collapses the 6 Age/Disability-specific “Assessment Only” Benefit Plans into one
  • Intended to provide reimbursement for individuals who need assessment but end up ineligible for any other Benefit Plan (no concurrency allowed)
  • Covers up to two assessments per year
  • Eligibility is limited to 60 days
ami benefit plan revision
AMI Benefit Plan Revision

Add to the list of Level of Functioning or Risk Factors:


i. Any individual with chronic mental illness who is currently stable but without continued treatment and supports would likely experience significant decompensation and deterioration of functioning.

  • The Benefit Plans that are expiring will be end-dated effective July 31, 2014 dates of service.
  • Any consumers actively receiving services who are in these Benefit Plans only (and not in one of the remaining plans) will need to be switched to one of the remaining plans by this date.
  • This is consistent with the August 1, 2014 implementation date for the DSM-5.
implementation has 2 stages
Implementation has 2 Stages:
  • Inclusion in DMHDDSAS Benefit Plans after July 31, 2014 shall be based on the covered DSM-5 diagnoses and eligibility criteria listed in the Diagnosis Array and Eligibility Criteria documents.
  • ICD-9 diagnosis codes covered in FY14 (see the last tab in the attached Diagnosis Array workbook) will continue to be allowed for claims adjudication in NCTRACKS through the end of FY15, for the Benefit Plans that are not expiring.
  • How to use the Diagnosis Array workbook
  • Q&A
  • Policy questions regarding these changes should be directed to Spencer Clark at
  • Technical questions should be emailed to