1. CUSTOMER SERVICES
STANDARDS TRAINING
[Date][Date]
[Place][Place]

2. Welcome
 This training will model the characteristics and theThis training will model the characteristics and the
practices of a high quality customer services unit:practices of a high quality customer services unit:
 Friendly, welcoming, open attitudeFriendly, welcoming, open attitude
 A gate-”opener” rather than a gate-”keeper”A gate-”opener” rather than a gate-”keeper”
 Customer services staff are systems navigatorsCustomer services staff are systems navigators
 Ready to helpReady to help
 Answers to your questionsAnswers to your questions

3. Customer Service At A Glance
E x t e r n a l Q u a lit y R e v ie w :
H e a lt h S e r v ic e s A d v is o r y G r o u p ( H S A G )
R e v ie w P r o t o c o ls : S t a n d a r d s V I , V I I & V I II
C o m m u n it y :
M e d ic a id B e n e fic ia r ie s w h o a r e p o te n t ia l
M e n t a l H e a lt h a n d S u b s t a n c e A b u s e
R e c ip ie n ts
C u r r e n t M e d ic a id B e n e f ic ia r ie s o f M H a n d S A S e r v ic e s
C u s t o m e r S e r v ic e s U n it
M a y b e d e le g a t e d b y P I H P s to C M H S P a f f ilia t e s ,
P r o v id e r N e t w o r k s ( e . g . , M C P N S ) o r,
S u b s t a n c e A b u s e C o o r d in a tin g A g e n c ie s ( C A s )
1 8 P r e - P a id I n p a t ie n t H e a lt h P la n s ( P I H P )
( M a n a g e M e d ic a id M e n t a l H e a lt h B e n e f it)
G o v e r n a n c e : M ic h ig a n D e p t . C o m m u n it y H e a lth
M e n ta l H e a lt h & S u b s t a n c e A b u s e S e r v ic e s
M D C H / P I H P C o n t r a c t : S e c t io n 6 .3
R e g u la t io n : B a la n c e d B u d g e t A c t o f 1 9 9 7
4 2 C F R * 4 3 8 . 1 0 ( I n f o r m a t io n R e q u ir e m e n t s )
* C o d e o f F e d e r a l R e g u la t io n

4. Background
 The federal Balanced Budget Act (BBA) of 1997The federal Balanced Budget Act (BBA) of 1997
was enacted after Congress heard criticalwas enacted after Congress heard critical
testimony from managed care recipients:testimony from managed care recipients:
 Lack of information about providersLack of information about providers
 No choice of providersNo choice of providers
 Health care decisions were made by personnelHealth care decisions were made by personnel
without clinical trainingwithout clinical training
 No due processNo due process

5. Background, II
 As a result, the BBA requires certainAs a result, the BBA requires certain
protections for beneficiaries enrolled inprotections for beneficiaries enrolled in
Medicaid health plansMedicaid health plans
 The BBA requires that Medicaid healthThe BBA requires that Medicaid health
plans meet managed care standardsplans meet managed care standards
 The BBA requires that external qualityThe BBA requires that external quality
reviews of their compliance be donereviews of their compliance be done
annuallyannually

6. Background, III
 In Michigan, Medicaid Pre-paid inpatient healthIn Michigan, Medicaid Pre-paid inpatient health
plans (PIHPs) were required to have customerplans (PIHPs) were required to have customer
service capacity by the 2002 Application forservice capacity by the 2002 Application for
Participation (AFP) and by their contract withParticipation (AFP) and by their contract with
MDCHMDCH
 AFP and MDCH contract had minimal descriptionAFP and MDCH contract had minimal description
of expectationsof expectations
 PIHPs were expected to review and adhere to thePIHPs were expected to review and adhere to the
BBA requirements and assure oversight andBBA requirements and assure oversight and
compliance by subcontractors to whom CS iscompliance by subcontractors to whom CS is
delegateddelegated

7. Background, IV
 The 2004 External Quality Review performed byThe 2004 External Quality Review performed by
Health Services Advisory Group (HSAG) foundHealth Services Advisory Group (HSAG) found
that most PIHPs did not meet the Standard VIthat most PIHPs did not meet the Standard VI
“Customer Service” Standard VII “Grievance“Customer Service” Standard VII “Grievance
Process”, or Standard VIII “Enrollee Rights”Process”, or Standard VIII “Enrollee Rights”
 MDCH determined that since this was a wide-MDCH determined that since this was a wide-
spread problem, Michigan standards for how aspread problem, Michigan standards for how a
customer services unit should operate and uniformcustomer services unit should operate and uniform
language for enrollee information should belanguage for enrollee information should be
developeddeveloped

8. Background, V
 Process:Process:
 Workgroup of the top performers and MDCHWorkgroup of the top performers and MDCH
staffstaff
 Consulted with HSAGConsulted with HSAG
 Developed draft standardsDeveloped draft standards
 Sought input from PIHPs, Recovery Council,Sought input from PIHPs, Recovery Council,
Quality Improvement Council and CustomerQuality Improvement Council and Customer
Services staffServices staff
 Revised per inputRevised per input
 Submitted recommendations to QualitySubmitted recommendations to Quality
Improvement Council: Approved standards onImprovement Council: Approved standards on

9. Background, VI
 Therefore, standards are not negotiableTherefore, standards are not negotiable

10. Preamble
 Front door: Welcome to Mental HealthFront door: Welcome to Mental Health
 Like a concierge service at a hotelLike a concierge service at a hotel
 ““Systems navigation” – link to the right peopleSystems navigation” – link to the right people
and right informationand right information
 Not a replacement for case managers, supportsNot a replacement for case managers, supports
coordinators or recipient rights advisors!coordinators or recipient rights advisors!
 Not a substitute for emergency accessNot a substitute for emergency access
 PIHP needs to clearly distinguish emergencyPIHP needs to clearly distinguish emergency
phone # from CS phone #phone # from CS phone #

11. Preamble, II
 Standards are for PIHPsStandards are for PIHPs
 If a PIHP delegates the customer servicesIf a PIHP delegates the customer services
function to an affiliate CMHSP, substancefunction to an affiliate CMHSP, substance
abuse coordinating agency or providerabuse coordinating agency or provider
network (e.g., MCPN): these standardsnetwork (e.g., MCPN): these standards
apply to them alsoapply to them also
 PIHP retains the responsibility for oversightPIHP retains the responsibility for oversight

12. Functions of Customer Services
Unit
 Welcome and OrientWelcome and Orient individuals to servicesindividuals to services
and benefits available, and the providerand benefits available, and the provider
networknetwork
 Provide informationProvide information about how to accessabout how to access
mental health, primary health, and othermental health, primary health, and other
community servicescommunity services
 HelpHelp individuals with problems andindividuals with problems and
inquiries regarding benefitsinquiries regarding benefits

13. Functions of Customer Services
Unit, II
 AssistAssist people with and oversee localpeople with and oversee local
complaint and grievance processescomplaint and grievance processes
 Track and reportTrack and report patterns of problem areaspatterns of problem areas
for the organizationfor the organization

14. Standard #1
 There shall be a designated unit calledThere shall be a designated unit called
“Customer Services”“Customer Services”

15. Standard #2
 There shall be at the PIHP a minimum ofThere shall be at the PIHP a minimum of
one FTE (full time equivalent) dedicated toone FTE (full time equivalent) dedicated to
customer services. If the function iscustomer services. If the function is
delegated, affiliate CMHSPs, substancedelegated, affiliate CMHSPs, substance
abuse coordinating agencies (CAs) andabuse coordinating agencies (CAs) and
network providers, as applicable, shall havenetwork providers, as applicable, shall have
additional FTEs (or fractions thereof) asadditional FTEs (or fractions thereof) as
appropriate to sufficiently meet the needs ofappropriate to sufficiently meet the needs of
the people in the service area.the people in the service area.

16. Standard #3
 There shall be a designated toll-freeThere shall be a designated toll-free
customer services telephone line and accesscustomer services telephone line and access
to a TTY number. The numbers shall beto a TTY number. The numbers shall be
displayed in agency brochures and publicdisplayed in agency brochures and public
information material.information material.

17. Standard #4
 Telephone calls to the customer servicesTelephone calls to the customer services
unit shall be answered by a live voiceunit shall be answered by a live voice
during business hours. Telephone menusduring business hours. Telephone menus
are not acceptable. A variety of alternativesare not acceptable. A variety of alternatives
may be employed to triage high volumes ofmay be employed to triage high volumes of
calls.calls.

18. Standard #5
 The hours of customer service unitThe hours of customer service unit
operations and the process for accessingoperations and the process for accessing
information from customer services outsideinformation from customer services outside
those hours shall be publicized.those hours shall be publicized.

19. Standard #6
 The customer handbook shall contain theThe customer handbook shall contain the
state-required topicsstate-required topics

20. Standard #7
 The Medicaid coverage name and theThe Medicaid coverage name and the
state’s description of each service shall bestate’s description of each service shall be
printed in the customer handbook.printed in the customer handbook.

21. Standard #8
 The customer handbook shall contain a dateThe customer handbook shall contain a date
of publication and revision(s).of publication and revision(s).

22. Standard #9
 Affiliate CMHSP, substance abuseAffiliate CMHSP, substance abuse
coordinating agency, or network providercoordinating agency, or network provider
names, addresses, phone numbers, TTYs,names, addresses, phone numbers, TTYs,
E-mails, and web addresses shall beE-mails, and web addresses shall be
contained in the customer handbook.contained in the customer handbook.

23. Standard #10
 Information about how to contact theInformation about how to contact the
Medicaid Health Plans or Medicaid fee-for-Medicaid Health Plans or Medicaid fee-for-
service programs in the PIHP service areaservice programs in the PIHP service area
shall be provided in the handbook (actualshall be provided in the handbook (actual
phone numbers and addresses may bephone numbers and addresses may be
omitted and held at the customers servicesomitted and held at the customers services
office due to frequent turnover of plans andoffice due to frequent turnover of plans and
providers)providers)

24. Standard #11
 Customer services unit shall maintain currentCustomer services unit shall maintain current
listings of all providers, both organizations andlistings of all providers, both organizations and
practitioners, with whom the PIHP has contracts,practitioners, with whom the PIHP has contracts,
the service they provide, languages they speak,the service they provide, languages they speak,
and any specialty for which they are known. Thisand any specialty for which they are known. This
list must include independent person-centeredlist must include independent person-centered
planning facilitators. Beneficiaries shall be givenplanning facilitators. Beneficiaries shall be given
this list initially and be informed annually of itsthis list initially and be informed annually of its
availability.availability.

25. Standard #12
 Customer services unit shall have access toCustomer services unit shall have access to
information about the PIHP includinginformation about the PIHP including
CMHSP affiliate annual report, currentCMHSP affiliate annual report, current
organizational chart, CMHSP boardorganizational chart, CMHSP board
member list, meeting schedule and minutesmember list, meeting schedule and minutes
that are available to be provided in a timelythat are available to be provided in a timely
manner to an individual upon request.manner to an individual upon request.

26. Standard #13
 Upon request, the customer services unitUpon request, the customer services unit
shall assist beneficiaries with the grievanceshall assist beneficiaries with the grievance
and appeals, and local dispute resolutionand appeals, and local dispute resolution
processes, and coordinate as appropriateprocesses, and coordinate as appropriate
with Fair Hearing Officers and the localwith Fair Hearing Officers and the local
Office of Recipient Rights.Office of Recipient Rights.

27. Standard #14
 Customer services staff shall be trained toCustomer services staff shall be trained to
welcome people to the public mental healthwelcome people to the public mental health
system and to possess current workingsystem and to possess current working
knowledge in, and know where in theknowledge in, and know where in the
organization detailed information can beorganization detailed information can be
obtained on at least the following…obtained on at least the following…

28. Standard #14.a.
 Information regarding the populationsInformation regarding the populations
served (serious mental illness, seriousserved (serious mental illness, serious
emotional disturbance, developmentalemotional disturbance, developmental
disability and substance use disorder) anddisability and substance use disorder) and
eligibility criteria for various benefits planseligibility criteria for various benefits plans
(e.g., Medicaid, Adult Benefit Waiver,(e.g., Medicaid, Adult Benefit Waiver,
MIChild)MIChild)

29. Standard #14.b.
 Service array (including substance abuseService array (including substance abuse
treatment services), medical necessitytreatment services), medical necessity
criteria, and eligibility for and referral tocriteria, and eligibility for and referral to
specialty servicesspecialty services

30. Standard #14.c.
 Person-centered planningPerson-centered planning

31. Standard #14.d.
 Self-determinationSelf-determination

32. Standard #14.e.
 RecoveryRecovery

33. Standard #14.f.
 Peer SpecialistsPeer Specialists

34. Standard #14.g.
 Grievance and appeals, Fair Hearings, localGrievance and appeals, Fair Hearings, local
dispute resolution processes, and Recipientdispute resolution processes, and Recipient
RightsRights

35. Standard #14.h.
 Limited English Proficiency (LEP) andLimited English Proficiency (LEP) and
cultural competencycultural competency

36. Standard #14.i.
 Information about Medicaid coveredInformation about Medicaid covered
services and referral within PIHPs as wellservices and referral within PIHPs as well
as outside to Medicaid Health Plans, Fee-as outside to Medicaid Health Plans, Fee-
for-Service practitioners, and Department offor-Service practitioners, and Department of
Human ServicesHuman Services

37. Standard #14.j: The Public
Mental Health System
 Structure
 Funding
 Services
 Protections

38. 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.

39. Funding
State taxes Federal Medicaid
State Appropriations
MDCH Federal Block
Grant funding
Services
County Mental Health
appropriation
CMHSP - GF contract
CMHSP - PIHP Affiliate agreement
PIHP Medicaid
contract

40. The Mental Health and Substance Abuse Treatment Delivery System in Michigan
The Private
Mental Health and Substance
Abuse Treatment System
The Public 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
Primarily made up of a
combination of State and
local taxes (GF),
recipient sliding scale
fees and co-pays
Medicaid
Fee for Service
(FFS)
Medicaid
Managed Care
Established under the state’s
Mental Health Code, the forty-
six (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
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 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.
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

41. 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.

42. 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.

43. 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

44. Standard #14.k.
 Balanced Budget Act relative to customerBalanced Budget Act relative to customer
services functions and beneficiary rightsservices functions and beneficiary rights
and protectionsand protections

45. Standard #14.l.
 Community Resources (e.g., advocacyCommunity Resources (e.g., advocacy
organizations, housing options, schools,organizations, housing options, schools,
public health agencies)public health agencies)

46. Standard #14.m.
 Public Health Code (for substance abusePublic Health Code (for substance abuse
treatment recipients if not delegated to thetreatment recipients if not delegated to the
substance abuse coordinating agency)substance abuse coordinating agency)

47. Customer Services Handbook
 Each PIHP must provide a beneficiary an up-to-Each PIHP must provide a beneficiary an up-to-
date handbook when they first come for servicesdate handbook when they first come for services
and periodically thereafterand periodically thereafter
 There are BBA-required topics that must be in theThere are BBA-required topics that must be in the
handbookhandbook
 There is MDCH-required language for someThere is MDCH-required language for some
topics to ensure consistency across the statetopics to ensure consistency across the state
 PIHPs may tailor information to reflect their localPIHPs may tailor information to reflect their local
operations and may add information to eachoperations and may add information to each
templatetemplate

48. Customer Services Handbook, II
 PIHPs that have quantity of handbooks onPIHPs that have quantity of handbooks on
hand may give these out as long as theyhand may give these out as long as they
contain or are supplemented with thecontain or are supplemented with the
required informationrequired information
 Drafts of new handbooks must be availableDrafts of new handbooks must be available
for review in the Spring 2007for review in the Spring 2007
 New handbooks must be distributedNew handbooks must be distributed
beginning October 1, 2007beginning October 1, 2007

49. Customer Services Handbook, III
 There are 12 topics that require the use ofThere are 12 topics that require the use of
template language.template language.
 They are not required to appear in this orderThey are not required to appear in this order

50. Template #1
 Confidentiality and family access toConfidentiality and family access to
informationinformation

51. Template #2
 Coordination of careCoordination of care

52. Template #3
 Emergency and after-hours access toEmergency and after-hours access to
servicesservices

53. Template #4
 GlossaryGlossary

54. Template #5
 Grievance and appealsGrievance and appeals

55. Template #6
 Language accessibility and accommodationLanguage accessibility and accommodation

56. Template #7
 Payment for ServicesPayment for Services

57. Template #8
 Person-centered planningPerson-centered planning

58. Template #9
 Recipient rightsRecipient rights

59. Template #10
 Recovery & ResiliencyRecovery & Resiliency

60. Template #11
 Service array, eligibility, medical necessity,Service array, eligibility, medical necessity,
and choice of providers in networkand choice of providers in network

61. Template #12
 Service authorizationService authorization

62. Other Required Handbook
Topics
 How to access the PIHP or CMHSPHow to access the PIHP or CMHSP
 How to obtain access to out-of-networkHow to obtain access to out-of-network
servicesservices

63. Other Required Handbook
Topics, II
 Affiliate [for Detroit-Wayne, the MCPNs]Affiliate [for Detroit-Wayne, the MCPNs]
addresses and phone numbersaddresses and phone numbers
 Executive directorExecutive director
 Medical directorMedical director
 Recipient Rights officerRecipient Rights officer
 Customer Services address & phoneCustomer Services address & phone
number, what it can do for customernumber, what it can do for customer

64. Other Required Handbook
Topics, III
 Community Resource list (includesCommunity Resource list (includes
advocacy organizations)advocacy organizations)
 IndexIndex
 Right to information about PIHP operationsRight to information about PIHP operations
(org chart, annual report, etc)(org chart, annual report, etc)
 Services not covered under contractServices not covered under contract
 Welcome to PIHPWelcome to PIHP

65. Other Suggested Handbook
Topics, IV
 Customer services phone number in theCustomer services phone number in the
footer of each pagefooter of each page
 Safety informationSafety information

66. Final Questions and Answers