Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

GBA 1 > Module 7 - Understanding Behavioral Health Care Benefits > Flashcards

Module 7 - Understanding Behavioral Health Care Benefits Flashcards

1
Q

(A) Behavioral Health Care

Definition

A
  • refers to mental health and substance abuse services provided by behavioral
    health specialists
  • behavioral health care benefits are subject to general forces of managed care while also facing unique issues and challenges of their own
  • there has been heightened focus on behavioral health care benefits because they are a key contributor to increased employee productivity and lower medical costs
  • of the 301 million American’s who have health insurance, 78% have some type of behavioral health care coverage
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

(A1) Behavioral Health Care

Mental Illness and Other Behavioral Health Disorders

A
  • most severe metal illnesses such as schizophrenia, bipolar disorder, and major depressive disorder are generally considered biologically based disorders that affect the brain, profoundly disrupting a person’s thinking, feeling, mood, ability to relate to others, and capacity for coping with the demands of life.
  • non-biologically mental disorders can also severely impact an individual’s functioning.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

(A1A) Behavioral Health Care

Mental Illness and Other Behavioral Health Disorders

Mental Disorders can loosely be categorized unto the following categories (9)

A

1 - Adjustment Disorders (situational stress)
2 - Anxiety Disorders (panic disorder)
3 - Childhood Disorders (autism)
4 - Eating Disorders (anorexia)
5 - Mood Disorders (major depressive disorder)
6 - Cognitive Disorders (dementia)
7 - Personality Disorders (antisocial personality disorder)
8 - Psychotic Disorders (schizophrenia)
9 - Substance-related disorders (alcohol or drug dependence)

  • 6% of adults in the US have been affected by one of the above
  • 20% of children in the US either currently or at some point in their lives have had a seriously debilitating mental disorder
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

(A2) Behavioral Health Care

The Need for Behavioral Health Care Benefits

A
  • Mental Illness is the leading cause of disability
  • Alcohol consumption accounts for a large percentage of industrial injuries and fatalities, and worker stress has been shown to greatly increase absences
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

(A3) Behavioral Health Care

Common Misconceptions

A
  • the mandated behavioral benefits in a medical plan are limited to emergency assessment and crisis coverage
  • mental health parity riders are limited in the scope of disorders they cover
  • EAP focus on workplace productivity and only offer a limited number of visits for emanational counseling
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

(B1) History and Industry Overview

The Early Years

A
  • Prior to the 1940’s, TX for mental disorders was only provided in state mental hospitals.
  • After WWII, general hospitals opened onsite psychiatric clinics and added psychiatrists to their staffs which prompted commercial insurance carriers to include hospitalization for mental illness
  • initially, this coverage provided the same level of benefits as for non-psych benefits
  • soon, insurers placed limits on outpatient mental health care because TX often continued for indefinite lengths of time and there was must subjectivity surrounding mental disorders and TX methods
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

(B2) History and Industry Overview

Growth of Managed Care

A

The Health Maintenance Organization (HMO) Act of 1973 promoted and set minimum standards for health maintenance organizations and required managed care plans to include an outpatient mental health benefit consisting of 20 visits annually for emergency assessment and crisis intervention.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

(B3) History and Industry Overview

The Behavioral Health Care Carve Out

A
  • The limitations of HMO coverage for mental health disorders led to the development of behavioral health care “carve-outs”.
  • a program that separated (or carves out) mental health and chemical dependency services from the medical plan and provides them separately, usually under a separate contract and from a separate company known as a managed behavioral health care organization (MBHO).
  • MBHO’s offer mental health and chemical dependency plans that fill the coverage gaps in medical plans and many also offer EAP’s.
  • they are also able to offer enriched, flexible, affordable behavioral health care benefits along with sophisticated administrative, operational and care management capabilities.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

(B4) History and Industry Overview

Growth of Employee Assistance Program

A

An EAP is a confidential resource for information and referral to emotional counseling, covering such matters as relationship issues, family conflicts, job-related stress, alcohol abuse, drug addiction, financial hardships, and other personal problems.

  • now considered a low cost, high-return tool for enhancing workplace productivity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

(C) Psychotropic Medication Management

A

Psychotropic Medications (primarily antidepressants) - drugs that affect psychic function, behavior, or experience - are part of the medical benefit and are generally administered by companies contracting with health plans called PBM’s.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

(D) Mental Health Parity

A

Mental Health Parity - equal insurance benefits for mental and medical disorders - is, in part, the result of years of work by groups such as the National Alliance for the Mentally Ill, govt. advocates, and thousands of supporters to erase the stigma society attaches to mental illness - to bring it out of the dark shadows and acknowledge it as a diseased as painful and often as life threatening physical illnesses.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

(D1) Mental Health Parity

The Mental Health Parity Act of 1996

A
  • prevents group health plans, insurance companies, and HMO’s from placing lower annual or life-time dollar limits on mental health benefits than on medical and surgical benefits under the plan
  • allows for limits on inpatient days, RX, outpatient visits, and raising deductibles
  • applies only to groups that offer medical health benefits and have more than 50 employees
  • does not apply to small groups under 50 or coverage in the individual market
  • does not address substance abuse or chemical dependency
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

(D2) Mental Health Parity

The Mental Health Parity and Addiction Equity Act of 2008

A
  • continues and extends on the The Mental Health Parity Act of 1996
  • requires parity in the coverage of mental health or substance abuse disorder benefits as compared with medical / surgical benefits in group plans.
  • effective for plan years beginning after 10/3/09
  • applies to both fully insured and self insured plans with 50+ employees
  • prevents plans from imposing financial requirements and treatment limitations applicable to MH/SUD
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

(D3) Mental Health Parity

The Mental Health Parity and Addiction Equity Act of 2008

The Parity Requirements apply to 6 Classifications of bBnefits

A 
1 - Inpatient In-Network 
2 - Inpatient Out-of-Network 
3 - Outpatient In-Network 
4 - Outpatient Out-of-Network 
5 - Emergency Care 
6 - RX
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

(E1) The Behavioral Health Care Market Today

Market Composition

A
  • the majority of behavioral health care benefits sold in the US are purchased by large groups that by comprehensive health care and other insurance benefits for their covered members
  • the smaller the group, the more likely it is that behavioral benefits are sold as an integrated part of a general health plan, which may or may not have a speciality MBHO provide the behavioral benefit.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

(E2) The Behavioral Health Care Market Today

The Sales Environment

A
  • sold through multiple channels
  • large brokerage and consulting firms often serve as the the go between for behavioral benefit purchasers, helping them locate and negotiate insurance contracts
  • a broker of consultant may also be an agency for an MBHO, delivering policies and collating premiums
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

(E3) The Behavioral Health Care Market Today

Changing Market Landscape

Four factors that have been cited as drivers of behavioral health care M&A

A

1 - payers were demanding greater capital reserves to pay providers more quickly and cover risk adequately
2 - greater investment was required in management information systems to meet accountability and accreditation requirements
3 - premium and capitation payments were stagnant, meaning that managed care companies were not seeing increases in revenues through existing business
4 - the cost involved in developing public procurement bids, especially for statewide contracts, could be large

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

(F1) Behavioral Health Care Benefit Plans

Typical Plan Features

A
  • the vast majority of employer sponsored health plans cover inpatient and outpatient mental health services
  • they cover intermediate mental health services such as residential treatment and partial (or day) hospitalization and intensive outpatient services
  • many include a parity benefit (often called a “severe mental illness” benefit) that specifics which disorders are covered dune their state parity law.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

(F2) Behavioral Health Care Benefit Plans

ERISA

A
  • Employee Retirement Income Security Act of 1974 regulates the majority of private pension and welfare group benefit plans in the US
  • the provisions of ERISA prevent states from regulating multi state employers on the provisions of their health benefits
  • affects many large self-insured employers and union trust groups
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

(F3) Behavioral Health Care Benefit Plans

HIPAA

A
  • The Health Insurance Portability and Accountability Act (HIPAA)
  • applies to all health insurance plans including MBHOs
  • allows employees to continue their health insurance coverage from one group to another
  • nondiscrimination provisions prohibit a group health plan or insurance company from denying an individual eligibility for benefits or charging an individual a higher premium based on a health factor
  • reduces health care fraud and abuse and protect privacy and is projected to significantly reduce the 29 cents of every health care dollar spent today on admin.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

(F3A) Behavioral Health Care Benefit Plans

HIPAA Administration Simplification component consists of 3 areas

A

1 - Data Standards; enforce standards for the electronic transmission of health care information
2 - Security; protects confidential and private information through sound and uniform security practices
3 - Privacy; maintains confidentiality of member information

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

(G1) Behavioral Health Care Benefit Plan Designs

Fully Insured Arrangements

A
  • often called “full risk” or “risk based”
  • two primary cost drivers for a fully insured funding arrangement are group utilization rates and unit costs for practitioner and facility care
  • a shared risk arrangement in which purchasers agree to assume financial risk for claims payment up to a certain amount
23
Q

(G2) Behavioral Health Care Benefit Plan Designs

Administrative Services Only (ASO)

A
  • an MBHO, for a fee, will handle medical management, utilization review, benefit, and other administrative functions such as claims payments
  • often called self funded or self insured
  • purchases assumes the financial risk for the health care costs of its members
  • network management
  • claims payment
24
Q

(H) Employee Assistance Programs

A
  • a confidential, short-term counseling service to assist employees and their family members with personal problems that negatively affect their job performance
25
Q

(H1) Employee Assistance Programs

Full Service EAP

A
  • offer a predetermined number of face to face counseling visits, generally from 3 to 8 per year.
  • community based
  • full array of work/life referral services (referrals are free to services incur costs), free information resources, and management consultation service
26
Q

(H2) Employee Assistance Programs

Work/Life Benefits EAP

A
  • a stepped down version of the full service EAP
  • includes all EAP services except for face to face counseling visits; these are often replaced with telephonic or web-based access to EAP counselors
27
Q

(H3) Employee Assistance Programs

Advantages of EAP

A
  • easy access to timely problem resolution
  • utilization tends to be high because accessing employee assistance carries less stigma than accessing behavioral health care benefits
  • proven cost management tool because it focuses on early resolution
  • must maintain continuing visibility to employees with posters, newsletters, mailings, email blasts, etc.
28
Q

(I) How Behavioral Health Benefits Work Together

A
  • an effective behavioral health program should include an integrated mental health/chemical dependency benefit that includes inpatient and outpatient services as well as EAP

Effectiveness relies on 3 things
1 - employee and employer awareness of the programs services and value
2 - appropriate use of the benefits
3 - how well the behavioral vendor and its network providers prevent and manage costly disorders

29
Q

(J) Behavioral Health Providers

A

-should be in a speciality network, have credentials, and meet the groups needs

30
Q

(J1) Behavioral Health Providers

The Speciality Network

A
  • includes individual (solo) practitioners and multi specialty group practices consisting of clinical psychologists, social workers, masters-level therapists, psychiatric nurses, and psychiatrists
  • may also include doctors who specialize in addictionology, and developmental behavior pediatricians to improve access for children with special needs
  • includes inpatient facilities and programs that accommodate the broad spectrum of treatment needs
  • acute inpatient facilities are for those who cannot care for themselves and may hurt themselves
  • partial hospital programs (sometimes called day treatment) offer intensive treatment during the day but patients return home at night
  • intensive outpatient programs are designed for patients who need more intensive treatment than weekly outpatient provides but they require fewer hours each day than partial or day facilities provide
31
Q

(J2) Behavioral Health Providers

Provider Qualification: The Credentialing Process

A
  • areas of scrutiny include investigation into a providers education, board certification, background and work history, liability insurance and malpractice coverage, practice information (addresses, hours, and facility description), population, language and treatment specialties, and hospital admitting privileges.
  • MBHO’s conduct re-credentialing, typically every two to three years, to ensure that providers maintain qualify standards
32
Q

(J3) Behavioral Health Providers

Meeting Group Needs: Customized Networks

A
  • often build custom behavioral provider networks to meet a groups diverse geographic, cultural, language, and specialty needs, as well as member preferences.
  • members have a choice of providers - outpatient, inpatient, specialized treatment
  • MBHO’s forge alliances with community based mental and substance abuse treatment providers both to provide covered services and as referral sources for non-covered services and they develop these linkages based on the particular need of the membership being served
  • beginning to consider telephonic or web-based psychiatry to serve rural populations that do not have access to local professionals
33
Q

(K) Behavioral Provider Payment Arrangements

3 Types of Payment Arrangements

A

1 - Fee for Service
2 - Capitation
3 - Per Diem and Case Rates

34
Q

(K1) Behavioral Provider Payment Arrangements

Fee For Service

A
  • the most widely used payment arrangement today
  • there is a payment for individual services at an established contact rate which is often negotiated and discounted based on the promise of a large volume of services
35
Q

(K2) Behavioral Provider Payment Arrangements

Capitation

A
  • a fixed payment, usually calculated on a per member per month basis, for the delivery of a defined range of behavioral services to a defined member population
  • financial risk is assumed by the provider and the providers profit is contingent on expending less money on caring for the capitated population than is received in capitation fees
  • group practitioners are more likely to handle capitation arrangements than solo practitioners
36
Q

(K3) Behavioral Provider Payment Arrangements

Per Diem and Case Rates

A
  • the most common payment arrangement for facilities and organized programs
  • a per diem rate is a negotiated and contracted daily rate for all services provided while a patient is in an inpatient program
  • a case rate, essentially a capitated arrangement for individual cases, is no longer common except in chemical dependency treatment when an MBHO may contract with a treatment facility or program to pay a flat fee for the treatment episode.
37
Q

(L) Care Management and Cost Control

A
  • include items such as care access, predictive modeling and assessment, performance management, outcomes management, and coordination of care
38
Q

(L1) Care Management and Cost Control

Care Access

A
  • MBHO’s require preauthorization to access treatment
  • operate their own customer service centers
  • members receiving routine referrals must be seen within 10 business days
  • if a members needs are urgent, an appointment is arranged within 48 hours
  • if a member is suicidal, referral is made to a hospital or inpatient facility if an immediate appointment is not available within the network
39
Q

(L2) Care Management and Cost Control

Predictive Modeling and Risk Assessment

A
  • high service utilizers, generally individuals with severe and persistent mental illnesses, represent a small percentage of overall service users but account for a disproportionate, higher percentage of treatment resources and claims costs
  • predictive modeling techniques provide the ability to forecast who those high-risk, potentially high-cost members are, and intervene in time to avoid preventable treatment costs
40
Q

(L3) Care Management and Cost Control

Performance Management

A
  • measure provider network performance through a number of variables which include accessibility, utilization, and adequacy and appropriateness of treatment
  • performance data is collected after the fact through provider assessment reports and claims data
  • some MBHO’s are collecting member-reported and provider-reported data earlier on in the process to guide timely treatment interventions that can avert unnecessary emergency hospitalizations and contribute to more effective treatment outcomes
  • profiling provider performance on clinical outcomes is an important step forward in the performance management arena
41
Q

(L4) Care Management and Cost Control

Case Management

A
  • refers to oversight of an MBHO’s members treatment to ensure it is appropriate
  • goals are crisis stabilization, prevention of long term disability, and reduced reliance on hospital care by facilitating patient engagement in outpatient treatment and community resources
42
Q

(L5) Care Management and Cost Control

Utilization Review and Management

A
  • determines the medical necessity and appropriateness of treatment being provided, and is performed at various times, including at the point of care (prospective review), during care (concurrent review), and after treatment (retrospective review)
  • utilize written criteria based on clinical evidence to guide the evaluation of medical necessity, appropriateness, and efficiency of mental health and chemical dependency services
43
Q

(L6) Care Management and Cost Control

Outcomes Management

A
  • developed tools to access treatment effectiveness and quantify outcomes, bringing technology, data, and increased objectivity to a field once dominated by subjective assessment
  • the measurement of outcomes concurrent with the treatment process is the most powerful approach to outcomes management because feedback to clinicians can shape care as it is being delivered
  • objective is to identify risks early so treatment interventions contribute to more positive outcomes as well as prevent emergencies and unnecessary hospitalizations
44
Q

(L7) Care Management and Cost Control

Coordination of Care

A
  • patients benefit from an interconnected services of care coordination protocols between behavioral health specialists, PCP/medical doctors, medical plans, MBHO’s, PBM’s, and community affiliates
45
Q

(L8) Care Management and Cost Control

Depression Disease Management Programs

A
  • support the clinician – patient relationship and plan of care, and emphasize prevention of disease related exacerbations and complications using evidence based guidelines and patient empowerment tools
  • require coordination among health plans, physicians, pharmacists, and patients
  • disease management can improve patient outcomes and equality of life while potentially reducing overall health care costs
46
Q

(L9) Care Management and Cost Control

Substance Abuse Relapse Programs

A
  • prevention of relapse is one of the critical elements in successful treatment
  • intensive outpatient treatment is more effective for most patients in treating chemical dependency
  • outpatient programs encourage you to remain sober while dealing with day to day life
  • offer after care programs to members who complete a course of chemical dependency treatment which are aimed at preventing relapse and often include telephonic support and self help tools
  • only patients with severe withdrawal and other medical complications now require hospitalization
47
Q

(M) MBHO Accreditation

A
  • may be accredited by the National Committee for Quality Assurance, the Utilization Accreditation Review Commission, and The Joint Commission
48
Q

(M1) MBHO Accreditation

National Committee for Quality Assurance

A
  • NCQA, nations largest accrediting body for HMO’s
  • an MBHO must demonstrate that it meets several quality standards, including standards covering access and triage to ensure that patients can see appropriate clinicians in a timely manner
  • also cover areas of network adequacy and they require that an MBHO demonstrate well-established liens of communication between PCP and their behavioral health practitioners
  • the highest level of NCQA MBHO accreditation is “full” which is effective for 3 years which is followed by a 1 year accreditation level and finally a provisional accreditation level after which NCQA will review the plan to see if it qualifies for a higher level
49
Q

(M2) MBHO Accreditation

Utilization Accreditation Review Commission

A
  • URAC
  • accredits health plans and PPO’s
  • offers 15 accreditation programs
  • the most common for MBHO’s being Core Accreditation and Health Utilization Management Accreditation
  • include organizational structure, staff qualifications, training and management, oversight of delegated activities, quality management, and consumer protection.
  • ensure that MBHO’s follow sound utilization management processes, respect patients and providers rights, maintain confidentiality, give payers reasonable guidelines, and are compatible with the 2002 US DOL claims regulations
50
Q

(M3) MBHO Accreditation

Joint Commission (TJC)

A
  • originated as the accrediting body for hospitals but TJC has been active in behavioral health care accreditation since 1972
  • to be eligible for a TJC survey, a behavioral health plan or integrated system must provide for health care services to be defined population of individuals, offer comprehensive and/or speciality services, and have both a centralized, integrated structure and contract with, or mange, actual care delivery sites, which include practitioner offices and/or components that deliver care
51
Q

(N) Future Developments in Behavioral Healthcare

A
  • only 36% of American adults with mental disorders are receiving treatment
  • some reasons for this are lack of insurance, cost, stigma, and not understanding what behavioral insurance covers
52
Q

(N1) Future Developments in Behavioral Healthcare

Broadening Care Access

A
  • proactive disease management programs that operate on several fronts; working with employers to out reach employees in the workplace and with health plans to identify patients taking psychotropic medications who need additional support and reaching out to patients with diabetes or heart disease who may also suffer from mental illness
  • outreach to people who want treatment but do not know how to access it or to find a therapist that is best for them
  • new ways of delivering therapy that are more accessible and cost effective; a “coach” who offers counseling over the phone or internet
53
Q

(N2) Future Developments in Behavioral Healthcare

Productivity

A
  • one of the challenges is the ability to demonstrate to purchasers that the benefits they deliver result in increased workplace productivity

GBA 1 (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions