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California Mental Health Parity Law Published: October, 2001 What the Mental Health Parity Law Means Coordinating Services Under Mental Health Parity Seriously Emotionally Disturbed (SED) Criteria Products and Services Available Behavioral Health Services What the Mental Health Parity Law Means Beginning in July 2000, California State Assembly Bill 88 (Mental Health Parity Law) is effective. Assembly Bill 88 requires coverage for nine diagnoses for severe mental illness (SMI) and serious emotional disturbance (SED) in children. These include: Schizophrenia Schizoaffective Disorder Bipolar Disorder Major Depression Obsessive-Compulsive Disorder Panic Disorder Eating Disorders (Anorexia Nervosa and Bulimia Nervosa) Autism or Pervasive Developmental Disorder Serious Emotional Disturbance in children and adolescents Health plans are required to cover SMI and SED benefits under AB88 . For medical reasons, continuity and cost effectiveness, PBH will manage the care for members who have a severe mental illness or serious emotional disturbance as defined by AB88. Coordination of care between PBH practitioners and Primary Care Physicians will assume greater importance than ever before. In addition, PBH recognizes that some severe behavioral health conditions may first be diagnosed in the primary care setting. PCPs play an essential role in facilitating access to behavioral health care - a role that can have a significant impact on a patient's health and well being. Therefore, in cases where a member is in treatment with more than one practitioner that includes the care of a PCP, treatment standards emphasize the importance of coordinating the patient's care among all providers. Under mental health parity in California, it is important for all caregivers to coordinate care and consult on the member's diagnosis so that benefits can be appropriately applied. Back to Top Coordinating Services Under Mental Health Parity The primary care setting is often the first point of access for many members who may require specialized behavioral healthcare services. While some parity diagnoses may be treated effectively in the primary care setting, some may require specialized psychiatric care and behavioral intervention by behavioral healthcare providers. Other diagnoses will be best treated through a combination of primary care intervention and behavioral intervention. The following guidelines are designed to assist practitioners in coordinating services under AB88. Autism or Pervasive Developmental Disorder: The medical benefit covers the physical examination, chromosomal studies, imaging studies, EEG, ophthalmology, otolaryngology (including hearing test), blood work and UA. PBH specialist providers will be responsible for psychiatric and psychological assessment, medication management, family therapy, and referral to community-based resources such as Regional Centers and Special Education programs. PBH has contracted with specialist providers and preferred facilities to manage members with autism or PDD, and who act as advocates for the member in accessing publicly funded programs of service. Eating Disorders: While eating disorders are considered to be primary psychiatric conditions, members with these disorders can have serious and life threatening medical complications. Coordination of care among PCPs and behavioral health practitioners is required to ensure that the member receives safe and effective treatment. Members with eating disorders usually present as outpatients. If the member first presents to a PBH contracted provider, he/she should be referred to the PCP for completion of a history and physical, and any relevant laboratory and imaging studies. The PBH specialist provider will initiate psychiatric or psychological assessment and ongoing care. The PCP and behavioral health professional(s) are expected to establish and remain in good communication with each other. The goal of this collaboration is to prevent de-compensation of the member to the point of requiring higher levels of medical or psychiatric care. Seriously Emotionally Disturbed: Children with serious emotional disturbance require a highly coordinated Treatment Plan that emphasizes the need for multi-systemic intervention to keep the child safely in the home and community. Under mental health parity, children and adolescents must meet the criteria for SED established by public law before they and their families are entitled to parity benefits: Back to Top Seriously Emotionally Disturbed (SED) Criteria The definition of Seriously Emotionally Disturbed (SED) is derived from public law. The criteria specify the degree and duration of functional impairment that must be present to qualify for services under the SED designation. It is important to note that SED is not a diagnosis nor is diagnosis alone the basis upon which the SED designation is applied. Practitioners who assess and diagnose children and adolescents should apply the following criteria to determine if the child or adolescent meets the definition of "Seriously Emotionally Disturbed:" One or more mental disorders as identified in DSM-IV that result in behavior inappropriate to the child's age; and who meet the criteria defined in the Welfare and Institutions Code. 1) The child has substantial impairment in at least 2 of the following areas: self-care, school functioning, family relationships or the ability to function in the community; and either of the following occur: the child is at risk of removal from the home or has already been removed the mental disorder and impairments have been present for more than 6 months or are likely to continue for more than 1 year without treatment 2) The child displays psychotic features, risk of suicide or risk of violence due to the mental disorder 3) The child meets special education eligibility requirements under Chapter 26.5 commencing with Section 7570 of Division 7 of Title 1 of the California Government Code Practitioners should note that children and adolescents who are assessed as meeting the above criteria are eligible for AB3632 services within the State of California. Practitioners should be prepared to advocate for and direct families through the Individualized Education Plan (IEP) process within the child's local school district. The IEP process is the vehicle through which children and families gain access to these state-funded resources. Back to Top Products and Services The majority of PacifiCare Behavioral Health enrollees have one of two basic benefit plans or products. Most members will have parity level benefits plus a supplemental benefit plan that covers non-parity diagnoses at the same co-payment level but with annual limits on the number of outpatient and inpatient days available to them. A smaller, but no less important group of members will have a parity-only benefit. For these enrollees, benefit coverage is only available to them if they are diagnosed with one of the nine diagnoses or conditions described under AB 88. Before benefits can be applied, it is essential that PBH refer the member with a parity-only benefit for assessment and diagnosis first. The second essential step is to then verify that the diagnosis meets the criteria established under AB 88 for parity level coverage. PBH accomplishes this through a review of both the Provider Assessment Report and the Life Status Questionnaire (or its adolescent version) completed by the member at the time of the assessment. PBH will authorize one assessment session for adults or two assessment sessions for children under the age of 18. Once a PBH Care Manager has reviewed the PAR and Y/LSQ, either authorization for treatment will be made or the enrollee will be sent a Notice of Non-Coverage (NONC) if they are determined not to have a serious mental illness or serious emotional disturbance of a child. Back to Top Available Behavioral Health Services Mental Health Services Psychiatric evaluation: A referral made to PBH-contracted psychiatrist to assess the patient's mental status and determine if there is a need for additional mental health care. Medication evaluation: A referral made to a PBH-contracted psychiatrist when there is a possible need to introduce a psychotropic medication into the Treatment Plan. Individual therapy: A referral made to a PBH-contracted practitioner, such as a Ph.D., Masters-level therapist, or Certified Counselor, to address issues that need individual, face-to-face assessment and treatment. Couples therapy: A referral made to a PBH-contracted practitioner, such as a Ph.D., Masters-level therapist, or Certified Counselor, when marital/relationship problems are having a negative impact on the patient. Family therapy: A referral made to a PBH-contracted practitioner, such as a Ph.D., Masters-level therapist, or Certified Counselor, when your patient's life situation and functioning are negatively affected by problems occurring within the family structure. PBH endorses family therapy involvement in the treatment of children and most adolescents. Psychiatric intensive outpatient: A referral to a facility-based program for the intensive treatment of a particular psychiatric disorder such as eating disorders or anxiety disorders. Intensive outpatient programs typically meet at least 9 hours per week and have a self-help recovery-based component. Partial hospitalization: A referral to a facility-based program ranging from 2 - 8 hours per day of supervised psychiatric treatment for member's whose psychiatric condition requires intensive stabilization, but the member is safe enough that they do not require an overnight stay. Psychiatric residential treatment: A referral to a facility for long term treatment of a chronic disorder when the member is unable to remain in the home or community. Most residential placements are for adolescents and contain an educational component. Inpatient treatment: A referral is made for inpatient care when services required exceed services available on an outpatient basis. Acute inpatient services are authorized when the member's condition requires 24-hour per day nursing and medical supervision to ensure the member's safety and to provide appropriate treatment. Back to Top Substance Abuse Services Important note: Services available may vary depending on the member's benefit plan. Please contact PBH directly to determine coverage for a specific patient. Assessment and Evaluation: A referral made to a PBH-contracted substance abuse professional or outpatient program to assess the patient's treatment needs and recommend appropriate treatment options. Outpatient treatment: A referral made to a PBH-contracted practitioner who specializes in the treatment of substance abuse in an office-based setting. This level of care is particularly appropriate for the following patient types: non-addicted patients with a pattern of substance abuse; patients who could benefit from a brief intervention to address motivation for change and treatment; and patients who require additional support to identify and fully utilize community self-help resources. Detoxification: In general, most uncomplicated detoxification can be safely and successfully accomplished on an ambulatory basis. If medical safety or other issues indicate that medically managed withdrawal should occur in an inpatient setting, PBH will offer a referral to a PBH-contracted facility. Intensive Outpatient Treatment: Intensive outpatient treatment (IOP) programs generally provide nine or more hours of structured programming per week, offered before or after work or school. Treatment plans are individualized and consist primarily of counseling and education. Additional medical or psychological services can be arranged as needed. These programs benefit addicted patients who require consistent professional support to establish sobriety and fully utilize community self-help resources. Residential treatment: Residential treatment programs are staffed 24 hours a day by substance abuse professionals and include on-site counseling, education and self-help meetings. Residential services may be appropriate on a short-term basis for addicted patients who are unable to maintain sobriety without 24-hour professional support or who live in a substance-saturated environment. Active discharge planning, focusing on transitioning the patient to a substance-free living situation and outpatient care, is initiated upon admission. Inpatient treatment: Interdisciplinary staff care for patients whose acute medical, emotional or behavioral problems are severe enough to require medical and nursing services on a 24-hour basis to achieve recovery. The treatment program is specific to an addictive disorder and is delivered at a PBH-contracted facility. Back to Top