1. health and fitness

CUSTOMER SERVICES
STANDARDS TRAINING
[Date]
[Place]
Welcome

This training will model the characteristics and the
practices of a high quality customer services unit:
 Friendly, welcoming, open attitude
 A gate-”opener” rather than a gate-”keeper”
 Customer services staff are systems navigators
 Ready to help
 Answers to your questions
Customer Service At A Glance
Regulation: Balanced Budget Act of 1997
42 CFR* 438.10 (Information Requirements)
*Code of Federal Regulation
Governance: Michigan Dept. Community Health
Mental Health & Substance Abuse Services
MDCH/PIHP Contract: Section 6.3
External Quality Review:
Health Services Advisory Group (HSAG)
Review Protocols: Standards VI, VII & VIII
18 Pre-Paid Inpatient Health Plans (PIHP)
(Manage Medicaid Mental Health Benefit)
Customer Services Unit
May be delegated by PIHPs to CMHSP affiliates,
Provider Networks (e.g., MCPNS) or,
Substance Abuse Coordinating Agencies (CAs)
Community:
Medicaid Beneficiaries who are potential
Mental Health and Substance Abuse
Recipients
Current Medicaid Beneficiaries of MH and SA Services
Background

The federal Balanced Budget Act (BBA) of 1997
was enacted after Congress heard critical
testimony from managed care recipients:
 Lack of information about providers
 No choice of providers
 Health care decisions were made by personnel
without clinical training
 No due process
Background, II
As a result, the BBA requires certain
protections for beneficiaries enrolled in
Medicaid health plans
 The BBA requires that Medicaid health
plans meet managed care standards
 The BBA requires that external quality
reviews of their compliance be done
annually

Background, III



In Michigan, Medicaid Pre-paid inpatient health
plans (PIHPs) were required to have customer
service capacity by the 2002 Application for
Participation (AFP) and by their contract with
MDCH
AFP and MDCH contract had minimal description
of expectations
PIHPs were expected to review and adhere to the
BBA requirements and assure oversight and
compliance by subcontractors to whom CS is
delegated
Background, IV


The 2004 External Quality Review performed by
Health Services Advisory Group (HSAG) found
that most PIHPs did not meet the Standard VI
“Customer Service” Standard VII “Grievance
Process”, or Standard VIII “Enrollee Rights”
MDCH determined that since this was a widespread problem, Michigan standards for how a
customer services unit should operate and uniform
language for enrollee information should be
developed
Background, V

Process:
 Workgroup of the top performers and MDCH
staff
 Consulted with HSAG
 Developed draft standards
 Sought input from PIHPs, Recovery Council,
Quality Improvement Council and Customer
Services staff
 Revised per input
 Submitted recommendations to Quality
Improvement Council: Approved standards on
Background, VI

Therefore, standards are not negotiable
Preamble

Front door: Welcome to Mental Health
 Like a concierge service at a hotel
 “Systems navigation” – link to the right people
and right information
 Not a replacement for case managers, supports
coordinators or recipient rights advisors!
 Not a substitute for emergency access
 PIHP needs to clearly distinguish emergency
phone # from CS phone #
Preamble, II
Standards are for PIHPs
 If a PIHP delegates the customer services
function to an affiliate CMHSP, substance
abuse coordinating agency or provider
network (e.g., MCPN): these standards
apply to them also
 PIHP retains the responsibility for oversight

Functions of Customer Services
Unit
Welcome and Orient individuals to services
and benefits available, and the provider
network
 Provide information about how to access
mental health, primary health, and other
community services
 Help individuals with problems and
inquiries regarding benefits

Functions of Customer Services
Unit, II
Assist people with and oversee local
complaint and grievance processes
 Track and report patterns of problem areas
for the organization

Standard #1

There shall be a designated unit called
“Customer Services”
Standard #2

There shall be at the PIHP a minimum of
one FTE (full time equivalent) dedicated to
customer services. If the function is
delegated, affiliate CMHSPs, substance
abuse coordinating agencies (CAs) and
network providers, as applicable, shall have
additional FTEs (or fractions thereof) as
appropriate to sufficiently meet the needs of
the people in the service area.
Standard #3

There shall be a designated toll-free
customer services telephone line and access
to a TTY number. The numbers shall be
displayed in agency brochures and public
information material.
Standard #4

Telephone calls to the customer services
unit shall be answered by a live voice
during business hours. Telephone menus
are not acceptable. A variety of alternatives
may be employed to triage high volumes of
calls.
Standard #5

The hours of customer service unit
operations and the process for accessing
information from customer services outside
those hours shall be publicized.
Standard #6

The customer handbook shall contain the
state-required topics
Standard #7

The Medicaid coverage name and the state’s
description of each service shall be printed
in the customer handbook.
Standard #8

The customer handbook shall contain a date
of publication and revision(s).
Standard #9

Affiliate CMHSP, substance abuse
coordinating agency, or network provider
names, addresses, phone numbers, TTYs, Emails, and web addresses shall be contained
in the customer handbook.
Standard #10

Information about how to contact the
Medicaid Health Plans or Medicaid fee-forservice programs in the PIHP service area
shall be provided in the handbook (actual
phone numbers and addresses may be
omitted and held at the customers services
office due to frequent turnover of plans and
providers)
Standard #11

Customer services unit shall maintain current
listings of all providers, both organizations and
practitioners, with whom the PIHP has contracts,
the service they provide, languages they speak,
and any specialty for which they are known. This
list must include independent person-centered
planning facilitators. Beneficiaries shall be given
this list initially and be informed annually of its
availability.
Standard #12

Customer services unit shall have access to
information about the PIHP including
CMHSP affiliate annual report, current
organizational chart, CMHSP board
member list, meeting schedule and minutes
that are available to be provided in a timely
manner to an individual upon request.
Standard #13

Upon request, the customer services unit
shall assist beneficiaries with the grievance
and appeals, and local dispute resolution
processes, and coordinate as appropriate
with Fair Hearing Officers and the local
Office of Recipient Rights.
Standard #14

Customer services staff shall be trained to
welcome people to the public mental health
system and to possess current working
knowledge in, and know where in the
organization detailed information can be
obtained on at least the following…
Standard #14.a.

Information regarding the populations
served (serious mental illness, serious
emotional disturbance, developmental
disability and substance use disorder) and
eligibility criteria for various benefits plans
(e.g., Medicaid, Adult Benefit Waiver,
MIChild)
Standard #14.b.

Service array (including substance abuse
treatment services), medical necessity
criteria, and eligibility for and referral to
specialty services
Standard #14.c.

Person-centered planning
Standard #14.d.

Self-determination
Standard #14.e.

Recovery
Standard #14.f.

Peer Specialists
Standard #14.g.

Grievance and appeals, Fair Hearings, local
dispute resolution processes, and Recipient
Rights
Standard #14.h.

Limited English Proficiency (LEP) and
cultural competency
Standard #14.i.

Information about Medicaid covered
services and referral within PIHPs as well
as outside to Medicaid Health Plans, Feefor-Service practitioners, and Department of
Human Services
Standard #14.j: The Public
Mental Health System
 Structure
 Funding
 Services
 Protections
General Service Structure
MDCH
Medicaid Prepaid
Inpatient Heath Plans
(18 PIHPs)
Community Mental
Health Services
Programs (46
CMHSPs)
Services
Each local CMHSP provides an array of Mental Health services through a network
of providers to adults with SPMI, children with SED, persons with DD and persons
with substance use disorders.
Funding
State taxes
Federal Medicaid
State Appropriations
MDCH
County Mental Health
appropriation
CMHSP - GF contract
CMHSP - PIHP Affiliate agreement
Federal Block
Grant funding
PIHP Medicaid
contract
Services
The Mental Health and Substance Abuse Treatment Delivery System in Michigan
The Private
Mental Health and Substance
Abuse Treatment System
Personal
Financial
Resources
Private
Insurance
including
Medicare
Private mental health
and substance use
disorder providers
include:
Addiction counselors,
Marriage counselors,
Licensed social workers,
Licensed psychologists,
Various types of therapists,
Physicians,
Psychiatrists
Private mental health clinics,
Private psychiatric hospitals
Substance Use
Disorder
Treatment
Combination of
personal,
resources, private
insurance and
Federal Block
Grant funding
Substance Abuse
Coordinating
Agencies (16)
arrange for
treatment through
a network of
licensed locally
based treatment
providers
The Public Mental Health and Substance Abuse Treatment System
Primarily made up of a
combination of State and
local taxes (GF),
recipient sliding scale
fees and co-pays
Established under the state’s
Mental Health Code, the fortysix (46) Community Mental
Health Services serving the
state’s eighty-three (83)
counties provide a full array of
of mental health services to
person with serious mental
health, serious emotional
disturbances, and
developmental disabilities
based upon their priority of
need.
Those applicants who are the
most involved and find
themselves most urgently in
need of services are a priority
for services. Those with lower
levels of needs may be either
placed on an agency’s waiting
list or referred to private
providers in the community for
service.
Other Services include the
Children's Waiver for children
with emotional disturbances,
the MI Child (limited benefit)
program, and the Adult Benefit
Waiver (limited benefit)
program
Medicaid
Fee for Service
(FFS)
This is a ten (10)
session annual
benefit provided by
any psychiatrist
accepting new
Medicaid FFS
patients.
There is also an
expanded benefit
from PIHPs and their
affiliate CMHSPs
when the person
requires a “specialty
level” of care
intervention
Medicaid
Managed Care
Medicaid Health Plans
(16 in the state?)
Provides Medicaid
beneficiaries with up to
Twenty (20) outpatient
sessions per year under
the basic mental health
benefit for persons with
mild to moderate mental
health needs. (no
substance use disorder
treatment)
Health Plan providers
are to refer
beneficiaries to the
PIHP or CMHSP
affiliate if beneficiary’s
level of care cannot be
adequately addressed
with outpatient services
Specialty Mental Health and
Substance Abuse Managed
Care Services made up of
PIHPs (18),
CMHSP affiliates (46)
and
Substance Abuse Coordinating
Agencies (16 in the state)
The PIHP and its affiliate
providers are responsible for
providing those Medicaid
beneficiaries with moderate to
severe needs with all B and B3
Specialty Services that are
medically necessary. The array
of potential services is
extensive and by design, very
flexible.
There are also three limited
enrollment waivers:
1. The (DD) Children’s waiver
which helps children remain
in their natural home who
otherwise would be admitted
to an ICF/MR,
2. The (Adult) Habilitation
Waiver (HAB) for persons
with developmental
disabilities who otherwise
would be admitted to an ICF/
MR, and
3. The SED waiver for children
with severe emotional
disturbances.
Mental Health Code Services
Within the available state funding …
priority for services shall be given to individuals with the most severe
forms of serious mental illness , serious emotional disturbances and
developmental disability, with priority to be given to those in urgent or
emergency situations…
Persons who do not meet this threshold of severity may be put on waiting
lists (or referred elsewhere) for services.
The public generally does not understand these financial and legal
limitations to service.
Medicaid Mental Health
Services
Medicaid beneficiaries presenting with a
specialty level of care are entitled to
receive all “medically necessary covered
services and supports from the CMHSP to
treat, ameliorate, diminish or stabilize their
mental health, developmental disability
and substance abuse conditions.
Recipient Protections
•
•
•
•
•
•
The person centered planning process
The individualized plan of service
Dedicated local Customer Service/problem
resolution staff
Local recipient rights protection system
Local dispute resolution process
Local Grievance and Appeal Process
•
And the Lansing-based Medicaid fair hearing process
Standard #14.k.

Balanced Budget Act relative to customer
services functions and beneficiary rights
and protections
Standard #14.l.

Community Resources (e.g., advocacy
organizations, housing options, schools,
public health agencies)
Standard #14.m.

Public Health Code (for substance abuse
treatment recipients if not delegated to the
substance abuse coordinating agency)
Customer Services Handbook




Each PIHP must provide a beneficiary an up-todate handbook when they first come for services
and periodically thereafter
There are BBA-required topics that must be in the
handbook
There is MDCH-required language for some
topics to ensure consistency across the state
PIHPs may tailor information to reflect their local
operations and may add information to each
template
Customer Services Handbook, II
PIHPs that have quantity of handbooks on
hand may give these out as long as they
contain or are supplemented with the
required information
 Drafts of new handbooks must be available
for review in the Spring 2007
 New handbooks must be distributed
beginning October 1, 2007

Customer Services Handbook, III
There are 12 topics that require the use of
template language.
 They are not required to appear in this order

Template #1

Confidentiality and family access to
information
Template #2

Coordination of care
Template #3

Emergency and after-hours access to
services
Template #4

Glossary
Template #5

Grievance and appeals
Template #6

Language accessibility and accommodation
Template #7

Payment for Services
Template #8

Person-centered planning
Template #9

Recipient rights
Template #10

Recovery & Resiliency
Template #11

Service array, eligibility, medical necessity,
and choice of providers in network
Template #12

Service authorization
Other Required Handbook Topics
How to access the PIHP or CMHSP
 How to obtain access to out-of-network
services

Other Required Handbook
Topics, II
Affiliate [for Detroit-Wayne, the MCPNs]
addresses and phone numbers
 Executive director
 Medical director
 Recipient Rights officer
 Customer Services address & phone
number, what it can do for customer

Other Required Handbook
Topics, III
Community Resource list (includes
advocacy organizations)
 Index
 Right to information about PIHP operations
(org chart, annual report, etc)
 Services not covered under contract
 Welcome to PIHP

Other Suggested Handbook
Topics, IV
Customer services phone number in the
footer of each page
 Safety information

Final Questions and Answers