/ AHCCCS Contractor Operations Manual
Chapter 400 - Operations

442 –Member with a Serious Mental Illness’ Request to Opt Out From a

Regional Behavioral Health Authority to an Acute Care

Contractor

Effective Date: xx/xx/xx,[1] 07/01/16

Staff responsible for Policy:DHCM - Operations[2]

  1. Purpose

This pPolicy applies to RBHA Contractorsand defines the criteria, process and timeframes that apply when a mmember is designated as with a SeriouslyMentallyIllness (SMI) requests a to transfer from receivinghis or her physical health care services from the assigned RBHA, to receiving physical health care services from an Acute Care Contractor[3].

  1. Definitions

Serious Mental Illness (SMI) / A condition as defined in A.R.S. § 36-550 and determined in a person 18 years of age or older.
Course of care / A period of time determined by a healthcare professional for the completion of treatment.
  1. Policy

The RBHA shall ensure the provision of physical health services for all Title XIX [4]enrolled members who are with a SMI (hereafter “Member”)[5] and shall work collaboratively with members and providers to address and resolve member concerns. A mMemberswith andesignated as determined SMI,whois are currently enrolled in a RBHA, may under exceptional circumstances [6]opt out of receiving physical health services from the RBHA and be transferred to an Acute Care Contractor for their his/her physical health servicesonly if they satisfy one or more of the applicable opt out limited criteria are satisfied[7]. Members who meet the opt out criteria The member will continue to receive behavioral health services through the RBHA.

  1. Exceptional CircumstancesOpt Out Criteria[8]

A Member will be Exceptional circumstancesOpt out criteria thatpermitted may result in the a transfer of a member [9] to may receive his/her acute/physical health care services from a RBHA to an Acute Care Contractor rather than the RBHA under the following conditions onlyfor physical health services, as defined by the 1115 waiver, are limited to[10]:

  1. The transfer is necessary due to RBHA nNetwork limitations and restrictions.
  2. A Member shall is unable of the RBHA that result in an issue with access to care. With respect for Primary Care Physicians (PCP), a member shall have a be able to select one Primary Care Physician (PCP) from a choice of at least twoat least two in-network PCPsPCP provider,s. and A Member shall have access to at least one specialty provider for each specialty area,, thato meet his/her their medical needs;, and/or,
  1. The transfer is necessary of the RBHA to fulfill a current physician’s or provider’s course of care recommendation; , and/or;,
  1. The SMI designated Mmember has demonstrable evidence which establishes that due to the enrollment and affiliation with the RBHA,as a person with an SMI, and in contrast to persons enrolled with an Acute Care Contractor, there is evidence to establish actual harm or the potential for discriminatory or disparate treatment exists with regard to:. This includes exists with regard to one or more of the following:
  1. a.The Aaccess to, continuity, or availability of acute care covered services; ,
  2. b.Exercising client member choice of plan; ,
  3. c.Privacy rights; ,
  4. d.Quality of services provided; , andand/or
  5. e.Client Member rights under Arizona Administrative Code, Title 9, Chapter 21, Article 29, Chapter 21, Article 2.[11]

With respect to 3(b), AaMmember, or his/herdesignee, shall demonstrate that discriminatory or disparate treatment has occurred or shall establish the plausible potential of such treatment. It is insufficient for a member to establish actual harm or the potential for discriminatory or disparate treatment solely on the basis that he/she is enrolled in the RBHA[12].

  1. Procedures[13]
  1. Members will receive information oaboutn the An opt out transfer process requested will be clearly documented in the RBHA Mmember Hhandbook and any other relevant member notices..
  1. Members who transition to the RBHA from an Acute Care Contractor who that are receiving active treatment withfrom a non-contracted provider please see ACOM Policy 402. shall be allowed to continue receiving treatment from the non-contracted provider through the duration of their prescribed treatment. Active treatment includes, but is not limited to: chemotherapy, pregnancy, a drug regime or scheduled procedure.
  1. The RBHA shall ensure that Mmembers have a choice ofof one from at least two PCPs. In addition, the RBHA will offer contracts to primary and specialist physicians who have established relationships with Mmembers to encourage provider continuity. For Mmembers who have an established relationship with a PCP that does not participate in the RBHA’s provider network, please see ACOM Policy 402. the RBHA will provide, at a minimum, a six6 month transition period during which the Mmember may continue to seek care from his/her established PCP while the member, the RBHA, and/or a case manager finds a PCP within the RBHA’s provider network.
  2. The RBHA shall develop and maintain a process allowing Mmembers designated with an SMI to request to the transfer their of physical health care services to an Acute Care Contractor in accordance with the opt out criteria and requirements herein. , as based on the exceptional circumstances aforementioned.
  1. The process shall must be initiated when the Mmember, the Mmember’s legal representative, or a medical provider with the Mmember’s consent, contacts by contacting the RBHA’s Member Services department verbally or in writing to request a change in the Mmember’s health care plan of enrollment. If the and the Mmember’s concern cannot be resolved to the member’shis/her satisfaction,. tThe process shall be , and facilitated through a centralized administrative RBHA functional area, such as Grievances and Appeals, and coordinated to include individuals who have the knowledge necessary to resolve the concern. [14]
  1. Upon receipt of a Mmember’srequest to transfer to an Acute Care Contractor, the RBHA must explore alall options and act to promptly resolve the Mmember’s concerns regarding:
  1. The availability and accessibility of services; , and/or

b. The course of medical care or delivery issues; , and/or

  1. Any policy or practice that results in the actual or perceived discriminatory or disparate treatment of the Mmemberindividual as a result of his/her enrollment in the RBHA.

4.All requested plan changes shall be processed as follows[15]:

a.

b.

c.Process for reviewing a member’s request to transfer to an Acute Care Contractor:

d.The process shall be initiated when the member, the member’s legal representative, or a medical provider with the member’s consent, contacts the RBHA’s Member Services verbally or in writing, to request a change in the member’s health care plan of enrollment, and the member’s concern cannot be resolved to the member’s satisfaction.

  1. All requested plan changesshall be processed as follows:
  2. The RBHA shall must enter all required information into the Opt Out Form , which is located on the web-based AHCCCS Client Portal. Thise form shall , and must be submitted for each member requesting to transfer to an Acute Care Contractor and shall to include the elements below:.:

i.Confirm and document that the member is designated as SMI and enrolled in the SMIaffiliated with the RBHA program;,[16].

ii.The Member’s request to opt-out (whether submitted in writing or taken verbally from the Member by the RBHA),

iii.If received verbally, writethe basis of the Mmember’s opt out request,;., ,

iv.All documentation provided by the Member related to his/her request,

ii.v.Attach any documentation provided by the Mmember, including evidence including but not limited to evidence establishing actual or potential harm,;,.

vi.Any relevant documentation obtained by the RBHA in response to the request (e.g. information regarding availability of services, treatment records, etc.), andDocument all efforts to investigate and resolve the Mmember’s concern,;., and

vii.Any additional findings or information obtained by the RBHA.

iii.

iv.Attach any evidence provided by the member of actual or reasonable likelihood of discriminatory or disparate treatment.

viii.Review completed opt out request packets, including all information received from the member or his/herdesignee, as described above,;, and

v..Ensure that a decision to deny the request, or a and recommendation to approve the approval or denial of the request, is .

ix.The final recommendation must be made approved by the RBHA Medical Director or designee.. [17]

  1. In the event a the RBHA denies a Member’s opt out request:[18]
  1. The RBHA shall submit the completed decision packet[i] to the AHCCCS Client Portal [19]and issue written notice to the Member within 10 calendar days from the date of receipt of the Member’s request. A complete decision packet shall include, at a minimum:.[20]

1)The Member’s request to opt-out (whether submitted in writing or taken verbally from the Member by the RBHA),

2)All documentation provided by the Member related to his/her request,

3)Any relevant documentation obtained by the RBHA in response to the request (e.g. information regarding availability of services, treatment records, etc.), and

4)Any additional findings or information obtained by the RBHA.[21]

  1. The denial notice issued by the RBHA shall list the information submitted by the Member with his/her request to opt out, include the specific reasons for denial and advise the Member of his/her right to appeal. This notice shall also include instructions to the Member detailing how to file the appeal with the RBHA.,
  2. In the event a Member appeals a denial of his/her request to opt out, the RBHA shall, within five business days of receipt of such appeal, provide the following documentation to AHCCCS:

1) The Member’s name, AHCCCS ID number, current address and telephone number (if applicable),

2) The Member’s initial opt out request,

3)The Member’s written appeal, and

4) The decision of the RBHA denying such request.[22]

  1. When a Member files an appeal regarding a RBHA’s of the denial of an opt out request, the RBHA shall appear at the administrative hearing prepared to and defend its decision to denydenial of the request. This includes legal representation at the administrative hearing and any subsequent proceedings.
  1. In the event athe RBHA recommends that a Member’s request to opt out be approved[23]: For a recommendation by the RBHA to approve the request:

i.

i.The RBHA shall Ssubmit to the AHCCCS Client Portal [24]the completed packet, together with all supporting any documentation it believes in any way relates to of the approval,to AHCCCS within sevencalendar days fromof receipt of the requestfrom the date of receipt of the Member’s request., to AHCCCS ffor a final AHCCCS decision.

ii.AHCCCS will approval.

iii.AHCCCS will issue a adecision to ll approve al or and deny ial decisionsthe request in writing within 10 three calendar days from the date of receipt of the completed packet from the RBHA., member’s initial request from the member.

ii.

iv.For requests that are denied by AHCCCS,AHCCCS will issue a notice to the Mmember that includes the reasons for the denial and the mMember’s right to appeal,. , and

iii.

iv.In the event the Mmember files an appeal and requests a hearing, AHCCCS will shall defend its decision to deny the request, which includes legal representation at the administrative hearing and any subsequent proceedings. present the case at hearing. The RBHA will shall provide AHCCCS with all requested information within a timeframe identified by AHCCCS. The RBHA willshall also allow its employee(s) to appear and testify at such hearing[25].

For a decision by the RBHA to deny the request:

The RBHA shall submit the completed packet to AHCCCS and issue written notice to the member within 10 calendar days from the date of the member’s request.

Notice issued by the RBHA shall include the reasons for the denial and the member’s right to appeal.

i.In the event the member files an appeal, the RBHA shall be responsible for defending their decision to deny the request, including legal representation and witness testimony.

  1. For any transfer ofa member with an SMIMemberenrolled in a RBHA to an Acute Care Contractor, the RBHA must (see ACOM Policy 402):
  1. Collaborate with the AHCCCS Acute Care Contractor to ensure appropriate transition and continuity of care. , and
  2. Maintain a record of all approved and deniedrequests to transfer to an Acute Care Contractor.
  1. Requests for an Administrative Hearing will be filed when:
  1. A Mmember, or his/herdesignee, who is dissatisfied with the decision to transfer to an Acute Care Contractor may request a hearing to dispute the decision. ,
  2. For RBHA denials of an opt out request, tThe Mmember’s request for hearingshallbe in writing and received by the RBHA Office of Grievance and Appeals no later than 30 calendar days from the date the Mmember receives the decision[26],
  3. For AHCCCS denials of an opt out request, the Member’s request for hearing shall be in writing and received by AHCCCS no later than 30 calendar days from the date the Member receives the decision. ,
  4. The Mmember may request that the hearing be expedited. The hearing shall be expedited if it isdetermined from the supporting documentation provided, or, a provider asserts, that taking the time for a standard resolution could seriously jeopardize the member’s life, health or ability to attain, maintain or regain maximum function. ,

d.Upon receipt of a timely request for hearing, AHCCCS the AHCCCS Office of Grievance and Appeals will forward the request to the Office of Administrative Legal Services (OALS) will to schedule a request for hearing and issue a Notice of Hearing., The documentation shall include:

e.The member’s name, AHCCCS ID number, current address and current phone number (if applicable),

f.The member’s request to transfer,

g.The decision, and

h.Any and all relevant information and/or documentation submitted by the member and any and all relevant information and/or documentation supporting the decision, including medical records.

  1. A Notice of Hearing will be issued when a timely request for hearing is filed.
  2. The AHCCCS Director or designee will issue a final agency the decision no later than 30 days from the date ofthe Administrative Law Judge’s recommended decision.,
  3. For requests for a hearing addressed pursuant to an expedited resolution timeframe, the Director or designee’s decision will be issued no later than threebusiness days after receipt of the Administrative Law Judge’s recommended decision. , and
  4. The RBHA shall fully cooperate with implementationof the Director or designee’sdecision, and ensure that coordination and continuity of care for the member is maintained throughout the process.

IV.References

RBHA Contract

A.R.S. §36-550

A.A.C. Title 9, Chapter 21, Article 2

CMS Waiver 1115[27]

Page 442-1 of 8

[1] Changes effective as a result of the new waiver

[2] Removing does not add value

[3] Grammatical and or changes to improve clarity

[4] Added applicable populationing who applies to

[5] Throughout policy, naming convention has been altered to “Member” to denote a member designated as SMI.

[6] Renamed to opt out criteria per below section

[7]. Reframed for clarity

[8] Renamed for clarity / alignment with policy language

[9]The diagnosis does not simply lead to an opt out of the physical health care component, it eliminates the SMI designation altogether and is more correctly a decertification.

[10] Reworded for clarity /section revised to align with language in 1115 waiver

[11] Changed ‘client’ to ‘member’ to align with policy language

[12] All changes in this section align with language included in 1115 waiver

[13] Content added and or revised to align with 1115 Waiver and/or opt-out process expectations.

[14] All changes to above section reflect clarifications to RBHA requirements/expectations and / or were reorganized from pre-existing sections of the policy

[15] Reorganized and moved from preexisting section of policy

[16] Edits to improve clarity, the term enrollment may be understood by the behavioral health system to mean that the person is receiving behavioral health services with a behavioral health provider, though they may not be receiving services but assigned as an integrated member based upon a historical SMI status.

[17] All previous edits to improve clarity

[18] Reorganized policy so that opt out denials and approvals are in separate sections under “Procedures” for clarity. Added language in below section reflects new opt out processes/requirements.

[19] POST APC CHANGE: clarification on how to submit

[20] Timelines and general requirements have not changed, however added language to align with updated process for RBHA denials.

[21] POST APC CHANGE: clarification on submission request

[22] Moved from a pre-existing section of policy

[23] Policy reorganized and approvals (and denials) of opt-out requests have a separate section for clarity. Added language throughout section to reflect updated requirements/ responsibility for opt out approvals.

[24] POST APC CHANGE: clarification on how to submit

[25] Added language to clarify responsibilities / expectations with updated process.

[26] As above, reorganized policy to detail requirements based on whether a request was approved or denied and aligned expectation with updated process.

[27] Removed reference list‐ applicable references are included in the policy

[i](Footnote to Include in Policy language) A completed decision packet shall include, at a minimum: (i) the Member’s request to opt-out (whether submitted in writing or taken verbally from the Member by the RBHA); (ii) all documentation provided by the Member related to his/her request; (iii) any relevant documentation obtained by the RBHA in response to the request (e.g. information regarding availability of services, treatment records, etc.); and (iv) any additional findings or information obtained by the RBHA.