NY Manual
SHP Manual

New York Provider Manual
9.1 Description of the Network | 9.3 Program Overview

​9.2 Benefits and Access to Care

Benefits Overview

All Healthfirst Medicaid members have access to Behavioral Health Services, including mental health and substance use disorder treatment. Services which were previously carved out of the managed care benefit package will be available to all Healthfirst Medicaid members on or after October 1, 2015.

Behavioral Health Services Include:

  • Inpatient - Substance Use and Mental Health
  • Outpatient Clinic - Substance Use and Mental Health
  • Personalized Recovery Oriented Services (PROS)
  • Intensive Psychiatric Rehabilitation Treatment Program (IPRT)
  • Assertive Community Treatment (ACT)
  • Continuing Day Treatment (CDT)
  • Partial Hospitalization
  • Comprehensive Psychiatric Emergency Program (CPEP)
  • Crisis Intervention
  • Opioid Treatment Programs
  • Outpatient Chemical Dependence Rehabilitation
  • Rehabilitation Services for Residential Substance Use Disorder Treatment Support

 

As of January 1, 2016, an additional array of Home and Community Based Services (HCBS) will be available to members who meet specific eligibility criteria, as defined by New York State. These services are designed to provide opportunities for Medicaid beneficiaries with serious mental illness and/or chronic substance use disorders to receive person-centered, recovery oriented services in their own community.

HCBS Services Include:

  • Rehabilitation Services such as: Psychosocial Rehabilitation and Community Psychiatric Support and Treatment (CPST)
  • Habilitation
  • Crisis Intervention Services such as: Short-term Crisis Respite and Intensive Crisis Intervention
  • Educational Support Services
  • Individual Employment Support Services such as: Pre-vocational, Transitional Employment Support, Intensive Supported Employment and Ongoing Supported Employment
  • Peer Supports
  • Support Services such as: Family Support and Training and Non-medical Transportation

  

Access to Care and Authorizations 

Members in need of services, or providers wishing to arrange services on behalf of a Healthfirst member, may call Member Services for information about network providers.

Healthfirst offers Behavioral Health Care Management by telephone for at-risk or high-risk members at no additional cost. Members who are receiving intensive outpatient services and those who are transitioning to lower levels of care may benefit from this program. In addition, our Medical Management department can provide referral or assignment to Health Home Care Coordination for those members who meet eligibility criteria. For further information about, or to refer a member for Healthfirst Behavioral Health Care Management or Health Home Services, please contact our Medical Management department at 1-888-394-4327, or the delegated Behavioral Health care management organization (as noted in the chart in Section 9.1).  

Authorization for traditional in-network outpatient Behavioral Health services delivered by Healthfirst providers is not required. Traditional outpatient Behavioral Health Services, as defined by Healthfirst for this purpose, include individual, group, and family therapy and medication management, provided alone or in any combination, to treat a behavioral health condition in a manner consistent with established clinical guidelines and provided at a frequency not exceeding five (5) hours a week.

Authorization is required for admissions, all out-of-network care, and select outpatient services such as: ECT, neuropsychological testing, and others. Members in need of care, or providers wishing to arrange these services for Healthfirst members, should call the Healthfirst Medical Management department at 1-888-394-4327 for assistance.

 

Commercial Plans

Healthfirst Leaf and HMO A-D plans include the following mental health and substance abuse benefits

(Note: Members associated with Montefiore, and Montefiore North, Elmhurst Medicaid LOB, will have their benefits managed by University Behavioral Associates. All other members will have the benefits managed directly by Healthfirst.)

Mental Health Care

·     Outpatient services relating to the diagnosis and treatment of mental health disorders are covered, including 
o     Unlimited outpatient visits
o     Partial hospitalization program services
o     Intensive outpatient program services
o     Services must be provided by a psychologist, psychiatrist, Psychiatric NP, or clinical social worker
o     Inpatient services relating to the diagnosis and treatment of mental health disorders

Substance Use Services

·     Inpatient services relating to the diagnosis and treatment of alcoholism and/or substance use and/or dependency are covered. This includes:
o     Detoxification and/or rehabilitation services as a consequence of chemical use and/or substance use
o     Outpatient services relating to the diagnosis and treatment of alcoholism and/or substance use and/or dependency
o     20 outpatient visits for family counseling. A family member will be covered, so long as that family member (i) identifies himself or herself as a family member of a person suffering from substance use and/or dependency, and (ii) is covered under the same family contract that covers the person receiving treatment for substance use, and/or dependence
 
 Depending on the plan, the member may have a copayment or coinsurance which will be applied towards his/her deductible.