CUSTOMER SERVICES STANDARDS TRAINING

[Date][Date]

[Place][Place]

Welcome

This training will model the characteristics and the This training will model the characteristics and the practices of a high quality customer services unit:practices of a high quality customer services unit: Friendly, welcoming, open attitudeFriendly, welcoming, open attitude A gate-”opener” rather than a gate-”keeper”A gate-”opener” rather than a gate-”keeper” Customer services staff are systems navigatorsCustomer services staff are systems navigators Ready to helpReady to help Answers to your questionsAnswers to your questions

Customer Service At A Glance

E x te rn a l Q u a lity R e v ie w :H e a lth S e rv ice s A d v iso ry G ro u p (H S A G )

R e v iew P ro to co ls : S ta nd a rds V I, V II & V III

C o m m u n ity:M e d ica id B e n e fic ia rie s w ho a re p o te n tia l

M e nta l H e a lth a n d S ub s tan ce A bu seR e c ip ie n ts

C u rre n t M e d ica id B e n e fic ia rie s o f M H a n d S A S erv ices

C u s to m e r S e rv ice s U n itM a y b e d e le g a te d by P IH P s to C M H S P a ff ilia te s,

P ro v id e r N e tw o rks (e .g ., M C P N S ) o r,S u b sta n ce A bu se Co o rd in a tin g A g e n cie s (C A s)

1 8 P re -P a id Inp a tien t He a lth P lan s (P IH P )(M a n ag e M e d ica id M e n ta l H e a lth B en e fit)

G o vern a n ce : M ich ig an D ep t. C om m un ity H e a lthM e n ta l H ea lth & S ub s tan ce A b u se S erv ices

M D C H /P IH P Co n trac t: S e ctio n 6 .3

R e gu la tio n : B a la nced B u d ge t A c t o f 19 974 2 C FR * 4 38 .1 0 (In fo rm a tion R e qu ire m e n ts)

*C o de o f F ed e ra l R eg u la tion

Background

The federal Balanced Budget Act (BBA) of 1997 The federal Balanced Budget Act (BBA) of 1997 was enacted after Congress heard critical was enacted after Congress heard critical testimony from managed care recipients:testimony from managed care recipients: Lack of information about providersLack of information about providers No choice of providersNo choice of providers Health care decisions were made by personnel Health care decisions were made by personnel

without clinical trainingwithout clinical training No due processNo due process

Background, II

As a result, the BBA requires certain As a result, the BBA requires certain protections for beneficiaries enrolled in protections for beneficiaries enrolled in Medicaid health plansMedicaid health plans

The BBA requires that Medicaid health The BBA requires that Medicaid health plans meet managed care standardsplans meet managed care standards

The BBA requires that external quality The BBA requires that external quality reviews of their compliance be done reviews of their compliance be done annuallyannually

Background, III

In Michigan, Medicaid Pre-paid inpatient health plans In Michigan, Medicaid Pre-paid inpatient health plans (PIHPs) were required to have customer service (PIHPs) were required to have customer service capacity by the 2002 Application for Participation capacity by the 2002 Application for Participation (AFP) and by their contract with MDCH(AFP) and by their contract with MDCH

AFP and MDCH contract had minimal description of AFP and MDCH contract had minimal description of expectationsexpectations

PIHPs were expected to review and adhere to the PIHPs were expected to review and adhere to the BBA requirements and assure oversight and BBA requirements and assure oversight and compliance by subcontractors to whom CS is compliance by subcontractors to whom CS is delegateddelegated

Background, IV

The 2004 External Quality Review performed by The 2004 External Quality Review performed by Health Services Advisory Group (HSAG) found Health Services Advisory Group (HSAG) found that most PIHPs did not meet the Standard VI that most PIHPs did not meet the Standard VI “Customer Service” Standard VII “Grievance “Customer Service” Standard VII “Grievance Process”, or Standard VIII “Enrollee Rights” Process”, or Standard VIII “Enrollee Rights”

MDCH determined that since this was a wide-MDCH determined that since this was a wide-spread problem, Michigan standards for how a spread problem, Michigan standards for how a customer services unit should operate and uniform customer services unit should operate and uniform language for enrollee information should be language for enrollee information should be developed developed

Background, V

Process:Process: Workgroup of the top performers and MDCH staffWorkgroup of the top performers and MDCH staff Consulted with HSAGConsulted with HSAG Developed draft standardsDeveloped draft standards Sought input from PIHPs, Recovery Council, Quality Sought input from PIHPs, Recovery Council, Quality

Improvement Council and Customer Services staffImprovement Council and Customer Services staff Revised per inputRevised per input Submitted recommendations to Quality Improvement Submitted recommendations to Quality Improvement

Council: Approved standards on May 31, 2006; approved Council: Approved standards on May 31, 2006; approved uniform language on July 26, 2006uniform language on July 26, 2006

Contract and Financial Issues Committee approved July 13, Contract and Financial Issues Committee approved July 13, 20062006

Background, VI

Therefore, standards are not negotiableTherefore, standards are not negotiable

Preamble

Front door: Welcome to Mental HealthFront door: Welcome to Mental Health Like a concierge service at a hotelLike a concierge service at a hotel ““Systems navigation” – link to the right people Systems navigation” – link to the right people

and right informationand right information Not a replacement for case managers, supports Not a replacement for case managers, supports

coordinators or recipient rights advisors!coordinators or recipient rights advisors! Not a substitute for emergency accessNot a substitute for emergency access PIHP needs to clearly distinguish emergency PIHP needs to clearly distinguish emergency

phone # from CS phone #phone # from CS phone #

Preamble, II

Standards are for PIHPsStandards are for PIHPs If a PIHP delegates the customer services If a PIHP delegates the customer services

function to an affiliate CMHSP, substance function to an affiliate CMHSP, substance abuse coordinating agency or provider abuse coordinating agency or provider network (e.g., MCPN): these standards network (e.g., MCPN): these standards apply to them alsoapply to them also

PIHP retains the responsibility for oversightPIHP retains the responsibility for oversight

Functions of Customer Services Unit Welcome and OrientWelcome and Orient individuals to services individuals to services

and benefits available, and the provider and benefits available, and the provider networknetwork

Provide informationProvide information about how to access about how to access mental health, primary health, and other mental health, primary health, and other community servicescommunity services

Help Help individuals with problems and individuals with problems and inquiries regarding benefitsinquiries regarding benefits

Functions of Customer Services Unit, II AssistAssist people with and oversee local people with and oversee local

complaint and grievance processescomplaint and grievance processes Track and reportTrack and report patterns of problem areas patterns of problem areas

for the organizationfor the organization

Standard #1

There shall be a designated unit called There shall be a designated unit called “Customer Services”“Customer Services”

Standard #2

There shall be at the PIHP a minimum of There shall be at the PIHP a minimum of one FTE (full time equivalent) dedicated to one FTE (full time equivalent) dedicated to customer services. If the function is customer services. If the function is delegated, affiliate CMHSPs, substance delegated, affiliate CMHSPs, substance abuse coordinating agencies (CAs) and abuse coordinating agencies (CAs) and network providers, as applicable, shall have network providers, as applicable, shall have additional FTEs (or fractions thereof) as additional FTEs (or fractions thereof) as appropriate to sufficiently meet the needs of appropriate to sufficiently meet the needs of the people in the service area.the people in the service area.

Standard #3

There shall be a designated toll-free There shall be a designated toll-free customer services telephone line and access customer services telephone line and access to a TTY number. The numbers shall be to a TTY number. The numbers shall be displayed in agency brochures and public displayed in agency brochures and public information material.information material.

Standard #4

Telephone calls to the customer services Telephone calls to the customer services unit shall be answered by a live voice unit shall be answered by a live voice during business hours. Telephone menus during business hours. Telephone menus are not acceptable. A variety of alternatives are not acceptable. A variety of alternatives may be employed to triage high volumes of may be employed to triage high volumes of calls.calls.

Standard #5

The hours of customer service unit The hours of customer service unit operations and the process for accessing operations and the process for accessing information from customer services outside information from customer services outside those hours shall be publicized.those hours shall be publicized.

Standard #6

The customer handbook shall contain the The customer handbook shall contain the state-required topicsstate-required topics

Standard #7

The Medicaid coverage name and the The Medicaid coverage name and the state’s description of each service shall be state’s description of each service shall be printed in the customer handbook.printed in the customer handbook.

Standard #8

The customer handbook shall contain a date The customer handbook shall contain a date of publication and revision(s).of publication and revision(s).

Standard #9

Affiliate CMHSP, substance abuse Affiliate CMHSP, substance abuse coordinating agency, or network provider coordinating agency, or network provider names, addresses, phone numbers, TTYs, names, addresses, phone numbers, TTYs, E-mails, and web addresses shall be E-mails, and web addresses shall be contained in the customer handbook.contained in the customer handbook.

Standard #10

Information about how to contact the Information about how to contact the Medicaid Health Plans or Medicaid fee-for-Medicaid Health Plans or Medicaid fee-for-service programs in the PIHP service area service programs in the PIHP service area shall be provided in the handbook (actual shall be provided in the handbook (actual phone numbers and addresses may be phone numbers and addresses may be omitted and held at the customers services omitted and held at the customers services office due to frequent turnover of plans and office due to frequent turnover of plans and providers)providers)

Standard #11

Customer services unit shall maintain current Customer services unit shall maintain current listings of all providers, both organizations and listings of all providers, both organizations and practitioners, with whom the PIHP has contracts, practitioners, with whom the PIHP has contracts, the service they provide, languages they speak, the service they provide, languages they speak, and any specialty for which they are known. This and any specialty for which they are known. This list must include independent person-centered list must include independent person-centered planning facilitators. Beneficiaries shall be given planning facilitators. Beneficiaries shall be given this list initially and be informed annually of its this list initially and be informed annually of its availability.availability.

Standard #12

Customer services unit shall have access to Customer services unit shall have access to information about the PIHP including information about the PIHP including CMHSP affiliate annual report, current CMHSP affiliate annual report, current organizational chart, CMHSP board organizational chart, CMHSP board member list, meeting schedule and minutes member list, meeting schedule and minutes that are available to be provided in a timely that are available to be provided in a timely manner to an individual upon request.manner to an individual upon request.

Standard #13

Upon request, the customer services unit Upon request, the customer services unit shall assist beneficiaries with the grievance shall assist beneficiaries with the grievance and appeals, and local dispute resolution and appeals, and local dispute resolution processes, and coordinate as appropriate processes, and coordinate as appropriate with Fair Hearing Officers and the local with Fair Hearing Officers and the local Office of Recipient Rights.Office of Recipient Rights.

Standard #14

Customer services staff shall be trained to Customer services staff shall be trained to welcome people to the public mental health welcome people to the public mental health system and to possess current working system and to possess current working knowledge in, and know where in the knowledge in, and know where in the organization detailed information can be organization detailed information can be obtained on at least the following…obtained on at least the following…

Standard #14.a.

Information regarding the populations Information regarding the populations served (serious mental illness, serious served (serious mental illness, serious emotional disturbance, developmental emotional disturbance, developmental disability and substance use disorder) and disability and substance use disorder) and eligibility criteria for various benefits plans eligibility criteria for various benefits plans (e.g., Medicaid, Adult Benefit Waiver, (e.g., Medicaid, Adult Benefit Waiver, MIChild)MIChild)

Standard #14.b.

Service array (including substance abuse Service array (including substance abuse treatment services), medical necessity treatment services), medical necessity criteria, and eligibility for and referral to criteria, and eligibility for and referral to specialty servicesspecialty services

Standard #14.c.

Person-centered planningPerson-centered planning

Standard #14.d.

Self-determinationSelf-determination

Standard #14.e.

RecoveryRecovery

Standard #14.f.

Peer SpecialistsPeer Specialists

Standard #14.g.

Grievance and appeals, Fair Hearings, local Grievance and appeals, Fair Hearings, local dispute resolution processes, and Recipient dispute resolution processes, and Recipient RightsRights

Standard #14.h.

Limited English Proficiency (LEP) and Limited English Proficiency (LEP) and cultural competencycultural competency

Standard #14.i.

Information about Medicaid covered Information about Medicaid covered services and referral within PIHPs as well services and referral within PIHPs as well as outside to Medicaid Health Plans, Fee-as outside to Medicaid Health Plans, Fee-for-Service practitioners, and Department of for-Service practitioners, and Department of Human ServicesHuman Services

Standard #14.j: The Public Mental Health System

Structure

Funding

Services

Protections

General Service Structure

MDCH

Medicaid Prepaid Inpatient Heath Plans (18 PIHPs)

Community Mental Health Services Programs (46

CMHSPs)

ServicesEach local CMHSP provides an array of Mental Health services through a network of providers to adults with SPMI, children with SED, persons with DD and persons with substance use disorders.

Funding

State taxes Federal Medicaid

State Appropriations

MDCH Federal Block Grant funding

Services

County Mental Health appropriation

CMHSP - GF contract CMHSP - PIHP Affiliate agreement

PIHP Medicaidcontract

The Mental Health and Substance Abuse Treatment Delivery System in Michigan

The PrivateMental Health and Substance

Abuse Treatment SystemThe Public Mental Health and Substance Abuse Treatment System

PersonalFinancial

Resources

PrivateInsuranceincludingMedicare

Private mental healthand substance usedisorder providers

include:

Addiction counselors,Marriage counselors,Licensed social workers,Licensed psychologists,Various types of therapists,Physicians,PsychiatristsPrivate mental health clinics,Private psychiatric hospitals

Primarily made up of acombination of State and

local taxes (GF),recipient sliding scale

fees and co-pays

MedicaidFee for Service

(FFS)

MedicaidManaged Care

Established under the state’sMental Health Code, the forty-six (46) Community MentalHealth Services serving thestate’s eighty-three (83)counties provide a full array ofof mental health services toperson with serious mentalhealth, serious emotionaldisturbances, anddevelopmental disabilitiesbased upon their priority ofneed.

Those applicants who are themost involved and findthemselves most urgently inneed of services are a priorityfor services. Those with lowerlevels of needs may be eitherplaced on an agency’s waitinglist or referred to privateproviders in the community forservice.

Other Services include theChildren's Waiver for childrenwith emotional disturbances,the MI Child (limited benefit)program, and the Adult BenefitWaiver (limited benefit)program

This is a ten (10)session annualbenefit provided byany psychiatristaccepting newMedicaid FFSpatients.

There is also anexpanded benefitfrom PIHPs and theiraffiliate CMHSPswhen the personrequires a “specialtylevel” of careintervention

Medicaid Health Plans(16 in the state?)

Provides Medicaidbeneficiaries with up toTwenty (20) outpatientsessions per year underthe basic mental healthbenefit for persons withmild to moderate mentalhealth needs. (nosubstance use disordertreatment)

Health Plan providersare to referbeneficiaries to thePIHP or CMHSPaffiliate if beneficiary’slevel of care cannot beadequately addressedwith outpatient services

Specialty Mental Health andSubstance Abuse ManagedCare Services made up of

PIHPs (18),CMHSP affiliates (46)

andSubstance Abuse Coordinating

Agencies (16 in the state)

The PIHP and its affiliateproviders are responsible forproviding those Medicaidbeneficiaries with moderate tosevere needs with all B and B3Specialty Services that aremedically necessary. The arrayof potential services isextensive and by design, veryflexible.

There are also three limitedenrollment waivers:1. The (DD) Children’s waiver

which helps children remainin their natural home whootherwise would be admittedto an ICF/MR,

2. The (Adult) HabilitationWaiver (HAB) for personswith developmentaldisabilities who otherwisewould be admitted to an ICF/MR, and

3. The SED waiver for childrenwith severe emotionaldisturbances.

Substance UseDisorder

Treatment

Combination ofpersonal,

resources, privateinsurance andFederal BlockGrant funding

Substance AbuseCoordinatingAgencies (16)

arrange fortreatment through

a network oflicensed locallybased treatment

providers

Mental Health Code Services

Within the available state funding … priority for services shall be given to individuals with the most severe forms of serious mental illness , serious emotional disturbances and developmental disability, with priority to be given to those in urgent or emergency situations…

Persons who do not meet this threshold of severity may be put on waiting lists (or referred elsewhere) for services.

The public generally does not understand these financial and legal limitations to service.

Medicaid Mental Health Services

Medicaid beneficiaries presenting with a specialty level of care are entitled to receive all “medically necessary covered services and supports from the CMHSP to treat, ameliorate, diminish or stabilize their mental health, developmental disability and substance abuse conditions.

Recipient Protections

• The person centered planning process• The individualized plan of service• Dedicated local Customer Service/problem

resolution staff• Local recipient rights protection system • Local dispute resolution process• Local Grievance and Appeal Process• And the Lansing-based Medicaid fair hearing process

Standard #14.k.

Balanced Budget Act relative to customer Balanced Budget Act relative to customer services functions and beneficiary rights services functions and beneficiary rights and protectionsand protections

Standard #14.l.

Community Resources (e.g., advocacy Community Resources (e.g., advocacy organizations, housing options, schools, organizations, housing options, schools, public health agencies)public health agencies)

Standard #14.m.

Public Health Code (for substance abuse Public Health Code (for substance abuse treatment recipients if not delegated to the treatment recipients if not delegated to the substance abuse coordinating agency)substance abuse coordinating agency)

Customer Services Handbook

Each PIHP must provide a beneficiary an up-to-Each PIHP must provide a beneficiary an up-to-date handbook when they first come for services date handbook when they first come for services and periodically thereafterand periodically thereafter

There are BBA-required topics that must be in the There are BBA-required topics that must be in the handbookhandbook

There is MDCH-required language for some There is MDCH-required language for some topics to ensure consistency across the statetopics to ensure consistency across the state

PIHPs may tailor information to reflect their local PIHPs may tailor information to reflect their local operations and may add information to each operations and may add information to each templatetemplate

Customer Services Handbook, II

PIHPs that have quantity of handbooks on PIHPs that have quantity of handbooks on hand may give these out as long as they hand may give these out as long as they contain or are supplemented with the contain or are supplemented with the required informationrequired information

Drafts of new handbooks must be available Drafts of new handbooks must be available for review in the Spring 2007for review in the Spring 2007

New handbooks must be distributed New handbooks must be distributed beginning October 1, 2007beginning October 1, 2007

Customer Services Handbook, III

There are 12 topics that require the use of There are 12 topics that require the use of template language.template language.

They are not required to appear in this orderThey are not required to appear in this order

Template #1

Confidentiality and family access to Confidentiality and family access to informationinformation

Template #2

Coordination of careCoordination of care

Template #3

Emergency and after-hours access to Emergency and after-hours access to servicesservices

Template #4

GlossaryGlossary

Template #5

Grievance and appealsGrievance and appeals

Template #6

Language accessibility and accommodationLanguage accessibility and accommodation

Template #7

Payment for ServicesPayment for Services

Template #8

Person-centered planningPerson-centered planning

Template #9

Recipient rightsRecipient rights

Template #10

Recovery & ResiliencyRecovery & Resiliency

Template #11

Service array, eligibility, medical necessity, Service array, eligibility, medical necessity, and choice of providers in networkand choice of providers in network

Template #12

Service authorizationService authorization

Other Required Handbook Topics How to access the PIHP or CMHSPHow to access the PIHP or CMHSP How to obtain access to out-of-network How to obtain access to out-of-network

servicesservices

Other Required Handbook Topics, II Affiliate [for Detroit-Wayne, the MCPNs] Affiliate [for Detroit-Wayne, the MCPNs]

addresses and phone numbersaddresses and phone numbers Executive directorExecutive director Medical directorMedical director Recipient Rights officerRecipient Rights officer Customer Services address & phone Customer Services address & phone

number, what it can do for customernumber, what it can do for customer

Other Required Handbook Topics, III Community Resource list (includes Community Resource list (includes

advocacy organizations)advocacy organizations) IndexIndex Right to information about PIHP operations Right to information about PIHP operations

(org chart, annual report, etc)(org chart, annual report, etc) Services not covered under contractServices not covered under contract Welcome to PIHPWelcome to PIHP

Other Suggested Handbook Topics, IV Customer services phone number in the Customer services phone number in the

footer of each pagefooter of each page Safety informationSafety information

Final Questions and Answers