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 adult members (age 21 and over) 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 for adults became available to all Healthfirst adult Medicaid members residing in New York City on October 1, 2015, and to adult Medicaid members residing on Long Island on July 1, 2016.

Beginning July 1, 2019, children ages 0–21 enrolled in Medicaid Managed Care will also have access to Behavioral Health services.

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 (IPRT) Program

  • 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 Adult Home and Community Based Services (HCBS) became available to members (age 21 and over) 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. On or after October 1, 2019, children ages 0–21 who are deemed eligible via an assessment will also have access to a children’s array of HCBS.

Adult HCBS 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: Prevocational, 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 Clinical Services department can provide referral or assignment to Health Home Care Management for those members who meet eligibility criteria. For further information, or to refer a member for Healthfirst Behavioral Health Care Management or Health Home Services, please contact our Clinical Services 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 Clinical Services 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:

Mental Health Care

• Outpatient services relating to the diagnosis and treatment of mental health disorders are covered, including:

o Unlimited outpatient visitso Unlimited outpatient visits

o Partial hospitalization program serviceso Partial hospitalization program services

o Intensive outpatient program services

o Services must be provided by a psychologist, a psychiatrist, a Psychiatric NP, or a 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. These include:

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 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 dependency

Depending on the plan, the member may have a copayment or coinsurance, which will be applied towards his/her deductible.

 
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