The Provision of Mental Health Services in Managed Care Organizations

Constance M. Horgan
Elizabeth Levy Merrick
Deborah W. Garnick
Dominic Hodgkin
Robert E. Cenczyk
R. William Lusenhop
Sarita Bhalotra

Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
Office of Managed Care
5600 Fishers Lane
Rockville, MD 20857

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	Acknowledgments
I.	Executive Summary
II.	Background and Study Methods
	Background
	Methods
	Organization of the Report
III.	Products and Contracting
	"Product" Definitions
	MCOs' Choice to Either "Make" or "Buy" Mental Health Services
	Contracting Arrangements for the Delivery of Mental Health Services
	Functions Delegated in Contracting Arrangements
	Risk Sharing
	Performance Standards
	Discussion
IV.	Benefits
	Types of Mental Health Services Covered
	Coverage Limits
	Copayment and Coinsurance Requirements for Outpatient Care
	Comparison of Cost Sharing for Mental Health and General Medical Care
	Prescription Drug Cost Sharing
	Discussion
V.	Screening and Treatment in Primary Care
	Requirements for Mental Health Screening in Primary Care
	Practice Guidelines for Mental Health Treatment in Primary Care
	Discussion
VI.	Entry Into Specialty Treatment
	Referral Process
	Prior Authorization Requirements
	Availability of 24-Hour Crisis Services
	Discussion
VII.	Treatment Process
	Providers of Mental Health Treatment
	Standards for Wait Time to Appointments
	Services for Patients With Both Mental Health and Substance Abuse Problems
	Utilization Review Personnel
	Organizational Responsibility for Initial Utilization Review and Appeals
	Mental Health Case Management Programs
	Discussion
VIII.	Quality Management
	Prevalence of Behavioral Health Quality Activities
	MCOs' Reporting of Results
	Practice Guidelines for Selected Mental Health Disorders
	Quality Assurance Committees for Mental Health Services
	Discussion
IX.	Conclusion
	Key Findings and Stakeholder Perspectives
	Service Delivery Models
	Interaction of Product Type and Contracting Arrangement
	Limitations
	Future Research
X.	References

Figures

II.1	Pathways to MBHOs
III.1	Frequency of Commercial Managed Care Product Types (Percentage of Products)
III.2	Types of Commercial Products Offered by MCOs
III.3	Frequency of Behavioral Health Contracting Arrangements (Percentage of Products)
III.4	Contracting Arrangements by Product Type
III.5	Functions Included by Different Contracting Arrangements
III.6	Risk-Sharing Arrangements in MCO Specialty Contracts
IV.1	Percentage of Products Covering Selected Mental Health Services
IV.2	Types of Limits on Mental Health Benefits
IV.3	Percentage of Products Using Copayment or Coinsurance for Outpatient Mental Health Visits (by Product Type)
IV.4	Percentage of Products Using Copayment or Coinsurance for Outpatient Mental Health Visits (by Contracting Arrangement)
IV.5	Average Coinsurance and Copayments for Outpatient Mental Health and General Medical Visits
IV.6	Average Coinsurance and Copayment Rates for Prescription Drugs
IV.7	Distribution of Copayment Amounts for Prescription Drugs
V.1	Percentage of Products Reporting Screening for Mental Health Problems
VI.1	Percentage of Products With Direct Self-Referral or Phone Center Referral for Specialty Mental Health Services (by Product Type and Contracting Arrangement)
VI.2	Percentage of Products With PCP or EAP Gatekeeping for Specialty Mental Health Services (by Product Type and Contracting Agreement)
VI.3	Availability of 24-Hour Mental Health Crisis Services
VII.1	Percentage of Products With Standards for Maximum Time to Initial Appointment
VII.2	Percentage of Products With Standards for Time to Follow-up Visits After Inpatient/Residential Discharge
VII.3	Percentage of Products With Specialized Approaches to Dually Diagnosed Patients
VII.4	Organizational Responsibility for Utilization Review and Appeals
VII.5	Percentage of Products With a Mental Health Case Management Program
VII.6	Percentage of Products Providing Specific Case Management Functions
VIII.1	Prevalence of Quality Management Activities by Product Type
VIII.2	To Whom Patient Satisfaction Survey Results Are Reported
VIII.3	Provision of Practice Guidelines for Selected Mental Health Disorders
VIII.4	Sources of MCOs' Mental Health Practice Guidelines (Percentage of Products)
VIII.5	Percentage of Products With Quality Assurance Committee for Mental Health and Substance Abuse Services

Tables

III.1	Percentage of Specialty Contracts for Claims and Administration1 With Written Performance Standards
IV.1	Distribution of Annual Limits on Outpatient Mental Health Visits
IV.2	Distribution of Annual Limits on Inpatient Mental Health Days
IV.3	Distribution of Lifetime Dollar Limits on Plan Payments for Mental Health
IV.4	Average Coinsurance and Copayment Rates for Outpatient Mental Health (by Product Type)
IV.5	Distribution of Outpatient Coinsurance and Copayment Amounts Across All Products
V.1	Percentage of Products That Distribute Practice Guidelines to PCPs, by Product Type and Contracting Arrangement
V.2	Percentage of Products With Practice Guidelines That Address Specific Topics, Among Those Requiring Guideline Distribution
VI.1	Percentage of Products Requiring Prior Authorization for Mental Health Services
VIII.1	Participation in MCO Quality Assurance Committees Overseeing Behavioral Health Services

Appendixes

A.	Summary of Survey Content

SMA03-3797
09/2003

The Provision of Mental Health Services in Managed Care Organizations

Table of Contents

Figures

Tables

Appendixes