Customer Services Standards Training by The State of Michigan


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  • Customer services staff or agents = systems navigators who facilitate the customer’s getting to the right people and the right information
    Customer = beneficiary or recipient
    While the standards are specific to Medicaid, one would hope that all customers who call or walk in will be treated with dignity and respect and will be helped to get the right information
    Review plan for the day.
    5 minute opportunity for questions at the end of each section. Write questions on 3x5 cards provided and we will collect them. We’ll answer all we can, or save until the end of the day. All questions and answers will be compiled and become part of the CD
  • Point out the chapter in the handout
    Most standards are BBA-required and reviewed as part of the External Quality Review
    Other standards were previously required by the AFP and contract
    Some standards resulted from Stakeholder feedback
    We have raised the bar of expectation and want best practice here in Michigan
  • Refer to these standards in the HSAG protocol in the Handout. This effort addresses Standards VI and VIII. It does not address Standard VII: Grievance Process. Much work has been done to refine the Grievance and Appeal Technical Requirement for PIHPs. It is believed that more training needs to be done.
    Enrollee rights is a misnomer. It is not about recipient rights, but rather about the beneficiary’s rights to information. Also, “enrollee” in this sense means the person who is a PIHP service recipient.
  • Top performers on 2004 External Quality Review: (100%) for Standard VI: Genesee, Lakeshore, Lifeways, Macomb, Northern Lakes,
    Standard VII (95% or better) Southwest Alliance, Lifeways, Thumb Alliance, Venture
    Standard VIII (95% or better) Venture and Lakeshore
  • Use an icebreaker here:
    When you go to a store’s (think Target, Meijers, Sears) customer services department to find out how where a product is located, or to order a special product, or discuss your bill, or start a bridal registry what do you expect?
    For example:
    A customer services rep is present!
    They are friendly
    They know the products, where to find them and can get you to a person who understands the product
    What else?
    Answers: welcoming, receptive & responsive, kind/caring, customer service etiquette, knowledgeable, good communication skills, available, sensitive, willingness to be helpful
  • Repeat caution about Customer Services not being substitute for case management or supports coordination. CS should give general information about benefits and services – the case manager or supports coordinator will specifically link the individual to benefits and services
    Customer services will help with general problems or inquiries, but again the case manager or supports coordinator will provide specific help
  • If people ask for help, customer services unit should be ready to assist them in completing the paperwork necessary to file a grievance or appeal an action to the local dispute resolution process or the state fair hearing process. In addition, if the complaint appears to be a recipient rights complaint, customer services should refer the individual or help him if necessary to the ORR
    The customer services unit should be be looking for trends of problems identified formally as grievances and appeals to the local dispute resolution process, as well as informal issues that customers bring to the unit. CS should work with the Quality Assessment and Performance Improvement Program to alert the QAPIP to problems areas that should be targeted for improvement processes.
  • This was a 2002 AFP requirement
    MDCH contract requirement and amendment #1
    Recognizable term in the “real world” that is synonymous with “help”
    Increased focus in this area as a result of the recent EQR to assure BBA compliance
    “Ombudsman” is not a reasonable substitute!
  • It is recommended that you develop a “rule of thumb” for the implementation of this standard within your PIHP.
    The PIHP has to have at least one FTE (could be spread across a couple of staff) and multiple affiliates. Additional FTEs should be added to meet the needs. What’s the test of “meeting the needs”? If someone has to wait for more than one business day to get a response from CS, then it is a sign that there are not enough dedicated staff.
    Assuming that the PIHP has at least one FTE, The CMHSP, CA or network providers do not need to have one FTE, but at least a portion of an FTE should be assigned. The amount of FTE should depend on the ability to sufficiently meet the needs of the people.
    Oversight of subcontractors by PIHP
    Best Practice: unit is separate from Recipient Rights, and Hearing Officers are not CS agents (conflict of interest, need to be neutral party)
    As with any of the standards, it is encouraged that you seek stakeholder feedback for planning and implementation recommendations for each of the standards.
    Be clear in your internal definition of the term “dedicated” to Customer Services.
  • The numbers in the brochure and PI material should indicate that this is the “Customer Services” number
    Web page needs to indicate that customers services number is toll free
    It is unacceptable to have a number posted that purports to be customer services, but requires that the customer hang up and dial a different number (rather than be transferred)
    The number must be truly designated…not an operator.
    Suggestion: use your internet capabilities as well.
    Explain TTY here
  • “Live voice” is not new
    Telephone menus or “trees” may not be used. The advertised customers services line must be answered by a live voice. It is acceptable to have a receptionist answer and transfer the call to CS staff or to their voice mail if the CS staff’s line is busy. CS staff should make every effort to return the call within one business day. If a CS unit has only one FTE, arrangements must be made for backup during his/her absence.
    Business hours: ask questions “How many of your customer services offices are closed during for a lunch hour?” “How many of you have customer services hours after regular business hours at least one day a week?”
    What do you do for back-up?
    Note: many consumers who are working or who have responsible family members who work, will use the lunch hour to call or visit the customer services office.
    Existing PIHP policy: supervisors should be monitoring responsiveness of CS unit
    Best Practice tip: include in job description of CS staff: competencies for responsiveness
    If time: ask about best practices for after hours and coverage
  • It is expected that the CS unit is open during the regular hours that the PIHP, CMHSP, CA or provider is open. For beneficiaries unable to call or visit CS during the hours (e.g. cannot get away from work), the CS unit must find a way to accommodate after hours calls – e.g., CS unit could be open for a time after business hours one night a week; or a CS staff could be on call for a time after business hours a couple nights a week.
    What are other ways that CS units provide after-hours assistance?
    At a minimum, the CS hours should be posted on a bulletin board near the office or on the door of the office, and be printed in the CS Handbook.
    Voice mails for after hours calls should contain information about the number to call in an emergency.
    Web page may contain information relative to how to make contact after regular business hours.
    Voice mail should not say “call back later” but identify who can help and give information on who to call during a clinical emergency.
    If time: ask for best practices.
    Encourage: be creative, be flexible to meet the callers’ needs.
  • We’ll talk more about the handbook. At this point you just need to know that the BBA requires that the PIHP has at a minimum the state-required topics. Some of the topics have uniform language that must be used. However, the PIHP may add to them, or insert its PIHP name into the body of the uniform language.
    If HSAG during the EQR approved your PIHP’s handbook you do not need to reprint at this time. If your PIHP was cited, then at a minimum you need to supplement your handbook with additional or revised material.
    By October 1, 2007, all PIHPs will need to implement the new handbook template.
    The new handbook will be posted on the MDCH web site and updated electronically.
  • Why? So that a beneficiary can go anywhere in the state and know that the same services are available and to assure that the names of the services are uniform in each PIHP area.
  • To assure that all PIHPs are utilizing the most current version
  • Only those entities affiliated with the PIHP.
    E-mails: only general agency e-mail addresses (not personal –mail addresses)
  • CS staff need be able to assist beneficiaries in linking to the Medicaid health plans or fee-for-service programs if asked. It would be helpful for CS staff to actually know names of people at the health plans or FFS programs. While it is not in the standards, CS staff should also know the state of Michigan’s Medicaid customer services hotline. Talk about experience of calling 1-800-642-3195 “Beneficiary Hotline.” Encourage staff to walk through this process so that they understand. Fee-for-service or “straight” Medicaid is a private arrangement between the practitioner and the beneficiary.
  • Yes! The beneficiary must be given a list of all the providers that the PIHP has. On an annual basis – for example at person-centered planning – the beneficiary should be reminded that the list is available and should be asked if she/he wants an updated copy.
    Note: Guardians should be given a copy of this information too.
  • The beneficiary should be informed that he has a right to information about the PIHP and given some examples of information he/she might request. Then the CS unit needs to be able to get its hands on the information fast. It would be helpful for people who are receiving services from an affiliate, CA or provider network to know how that entity fits into the overall PIHP. They may choose to request information about the PIHP and/or the affiliate.
  • According to the AFP, it is preferred that the CS unit provide the assistance with the grievance, appeals, and local dispute resolution process. Clarify “assistance”
    Give examples of the kinds of assistance
    Preferred wording from AFP
    Could be a link to the agent
    Provide education
  • Some of the following categories require that the CS staff have a more thorough knowledge, other categories the CS staff would be expected to refer the beneficiary to the proper expert.
    It is important to note the distinction again between the role of the customer services staff and the case manager or supports coordinator.
    It is expected that there will be evidence of the training that CS staff had in all of the following areas.
    Give examples of “working knowledge”
  • It is not expected that the CS staff determine whether an individual is eligible. They should however, know the boundary between GF (Mental Health Code) and Medicaid eligibility for specialty services, and the boundary between Medicaid Health Plan and PIHP eligibility.
    Be careful about “informal denials”!! CS staff should merely state the facts, not speculate or give an opinion about whether a person may or may not be eligible. That is for the access center!
    Refer to the handout, and to the Medicaid Provider Manual, and website where it is located. Note that not just the Mental Health and Substance Abuse chapter are relevant but also the practitioner’s, Home Help, and Medicaid Health Plans chapters
    CS staff should be able to describe eligibility criteria for the populations served, based upon the Mental Health Code and MDCH Contract. A working knowledge of the difference in eligibility criteria for various benefit plans is essential to facilitating access to services within the PIHP Network. For example, individuals enrolled in the Adults Benefit Waiver Program may contact a CS representative with questions/complaints related to accessing services. For example, CS staff should have awareness that ABW recipients are not required to meet criteria for serious mental illness, and are entitled to various specific services included in the benefit plan. CS staff are therefore able to assist the ABW caller with navigating through the system with full understanding of their right to receive specific services, and their appeal rights if these services are denied, suspended, or terminated.
    It is extremely important that CS staff do not address questions which are specific to determination of eligibility. When callers express concern regarding whether he/she is actually eligible for a specific benefit, such as ABW or MICHILD, CS staff should refer the caller to the appropriate provider agency/case manager/supports coordinator to address the concern. Eligibility determination will then be made through the assessment process. This is avoid “informal denial” of service. Informal denials occur when an individual seeking services is told he/she is not eligible, based upon verbal discussion, often phone contact, rather than face to face screening and assessment. Informal denials adversely impact potential beneficiaries, delay/deny access to services, and impede referral and coordination with appropriate alternative community resources.
  • CS staff should have the Medicaid Provider Manual (in the handout) at hand and know what services are potentially available (when someone asks about B3s the CS staff should know exactly what those are), know where the medical necessity criteria are located and what they mean, and know what eligibility an individual must have in order to receive the services (e.g., HSW and Children’s waiver have different criteria than the b waiver).
    Changes in the Medicaid Provider Manual occur frequently (at least quarterly). CS staff need to check the MDCH web site quarterly. In January of each year, the PIHP executive director receives a CD with the entire manual updated.
    Be careful about “informal denials”!! CS staff should merely state the facts, not speculate or give an opinion about whether a person may or may not be eligible for a particular service or for specialty services in general. That is for the access center or case manager/supports coordinator!
    Refer to grid of Medicaid services in the handout.
    CS staff should be have knowledge of services available within their PIHP for individuals and their families with special needs. Knowledge of services available for individuals who are deaf or visually impaired etc., is important to communicate and provide appropriate referral.
    CS staff must be aware of their particular PIHP contract for the delivery of substance abuse services. Some PIHP’s, for example, such as Detroit-Wayne County Community Mental Health Agency, contract with two Substance Abuse Coordinating Agencies (CA), the City of Detroit Bureau of Substance Abuse and Southeast Michigan Community Alliance (SEMCA) for delivery of substance abuse services. CS staff at Detroit Wayne would therefore need to provide the toll free telephone numbers for these two CA’s, based upon living address, to callers as needed
    It is important for CS to know the importance of the PCP process as related to the process of eligibility and referral for specialty services. CS staff should be aware of the Individualized Plan of Services/Person-Centered Plan as the foundation for determining medical necessity and referral to appropriate specialty services.
  • It is not expected that the CS staff be an expert in PCP. They should, however, know that it is a MH Code requirement to be available to all MH recipients. That it’s the opportunity for the person to plan his services and supports to meet his needs. They should also know that independent facilitation should be available and from whom. The case manager or supports coordinator will assist the beneficiary with starting the PCP process.
    CS knowledge of the PCP process requires regular staff training and evaluation. CS who are trained on the PCP Process will be able to understand the close correlation between PCP principles, and self-determination, recovery, etc.
    CS staff must understand, for example, that PCP is an on-going process, rather than a single event or annual meeting. This awareness enhances the CS staff to inform and empower individuals to actively participate in the process by contacting the supports coordinator/case manager for input and feedback regarding their IPOS/PCP.
    CS staff must have working knowledge of the PCP process as related to choice. Individuals may be easily overwhelmed with the number of professional staff with whom they must interact. CS staff will enhance individual confidence by providing concise information specific to their right to choose the supports and services needed to improve their lives and achieve hopes and dreams.
    CS staff must be aware of each individual’s option to select an “independent facilitator”. Knowledge of independent facilitation services should include: the process used by the PIHP to select independent facilitators; general understanding of the specific services provided by the independent facilitator (this may vary depending upon the specific contract negotiated between the independent facilitator and the PIHP); expected outcomes when utilizing independent facilitator services.
    CS staff who understand PCP, are then able to assist individuals to understand the grievance and appeal process as related to the IPOS/PCP. CS staff may be the first to note a violation of the individual’s rights specific to PCP, and facilitate filing a formal grievance, with their consent.
    CS staff must understand the requirement to include natural supports in the PCP process, based upon the Mental Health Code. Calls from individuals expressing lack of involvement of family and friends in this process, should be logged and carefully monitored. Trends involving same providers can then be analyzed to determine a need to other interventions, which may include site visits, training, etc.
    CS staff should possess knowledge of the principles of Self-Determination and Recovery, within the context of the PCP process, recognizing the positive outcomes directly related to active participation. This enable CS staff to enhance individual motivation to work with their case manager/supports coordinator to achieve personal goals and promote recovery and independence.
  • Again, the CS staff does not need to be fully versed in this. However, they should know what it is and who to refer the beneficiary to when he wants to know more about it.
    CS staff should have general knowledge of the PIHP policy specific to Self-Determination. Training to CS staff by the PIHP, should include a basic overview to include: definition of Self-Determination; Availability of the option to request Self-Determination within the PCP process; contact person(s) within the provider network for additional information/detailed questions/concerns.
    Basic understanding of the option of Self-Determination will facilitate CS to address misconceptions expressed by family/individuals seeking information. For example, an individual may ask, is it true that the ability to independently complete activities of daily living is a criteria for accessing self-determination? CS staff should be able to confidently address this question. Clarification to the caller that all medically necessary supports and services, including the B3 services, should be offered to promote and support independence and community integration. CS staff would then clarify that it is therefore not a requirement that individuals be fully independent in ADL activity to access a self-determination living arrangement.
  • Refer to SAMHSA description in handout. Note the existence of the state level Recovery Council
    CS staff should be able to provide clear description of the Recovery process, based upon: PIHP policy and procedures; SAMHSA Guidelines; and the MDCH Recovery Council.
    CS staff should be able to describe basic supports and services within the PIHP provider network which enhance and support recovery (i.e. peer support, self-determination; clubhouses, etc).
    CS staff training should include a basic overview of evidence based practice. This will enhance staff’s ability to understand the SAMHSA research related to interpreting and organizing mental health recovery and associated outcomes.
    CS staff are not required to be experts on the Recovery Process. A basic understanding of Recovery as a deeply personal journey is essential, and should include knowledge of the following key related concepts; hope, empowerment, consumer control, self-determination, peer support, choice, and independence.
    CS staff should be aware of the vision and overall mission of the Recovery Council which is on the MDCH web site.
  • Refer to the Medicaid Provider Manual. Also, note that Peer Specialists receive specific and intensive training
    You should know who the peer specialists are in your PIHP area
    CS staff should have current knowledge of the Peer Specialist Role and the relationship of this role to the overall Recovery process. CS staff should understanding the integral relationship of peer mentoring and counseling to the goals of hope, empowerment, independence, and recovery.
    CS staff should be aware of the intensive trainings provided through MDCH for certification as a peer support specialist. Five more trainings will be held before the end of calendar year 2007. This is important in the event consumers contact CS staff requesting information regarding how they may become a peer specialist. While the call may need to be appropriately referred to the case manager/supports coordinator for follow up, the initial information provided will allow the consumer to determine if this is indeed a role he/she wishes to pursue.
    CS knowledge of who the peer support specialist are within the PIHP provider network is also important. This information allows the CS staff to provide the necessary support and monitoring of peer support specialist within the PIHP network. As per the Medicaid Provider Manual, Peer Support Specialist must be trained and supervised by a PIHP/CMHSP case manager or supports coordinator. Direct referral to a particular peer support specialist for individual counseling is also an added benefit.
  • This training will not be a “seminarette” on these topics. Responsible staff should attend the specific trainings on grievance and appeals and Fair Hearings. Next session: Oct 12th & 13th Crystal Mtn. Contact MACMHB
    They don’t need to have thorough knowledge of RR system but should be able to recognize when a right has been violated and be able to refer the consumer to the local ORR.
    Know the Fair Hearing Coordinator and Recipient Rights Officers in the PIHP area by name
  • Refer to LEP guideline in handout
    Tips for how to use local language interpreters
    This is more than foreign language – it also addresses how people from different cultural backgrounds should be treated, and it includes accommodations for people who are hearing and sight impaired
    Should have a familiarity with the processes your PIHP uses to assist with LEP and cultural competence wiithin your service delivery system.
  • Note the Medicaid Provider Manual in the handout and the services grid.
    This is where the CS staff needs to excel as systems navigators! Note the distinction between the CS role and the roles of case manager and supports coordinator here.
  • List the relative sections of the BBA 42CFR 438.10 in handout
  • Another area where CS staff ought to be well-versed but care should be taken not to assume the role of case manager or supports coordinator. PIHPs will need to assemble their own list of community resources.
  • If the PIHP has not delegated the CS function to the SA coordinating agency, then the PIHP CS staff need to know that the Public Health Code regulates SA services. Refer to link in the handout
  • “Up-to-date” is a local PIHP determination
  • New means handbooks with all the required topics and boilerplate language
  • Trainer: refer audience to handout and the handbook template language for all these templates
    In reference to HIPAA- the US Department of health and Human Services; “The privacy rule establishes, for the first time, a foundation of Federal protections for the privacy of protected health information. The rule does not replace Federal, State or other laws that may grant a greater degree of protection…”
    The state also has laws protecting confidentiality. These include:
    Sections 748 of the Mental Health Code, Confidentiality in the Recipient Rights
    Section 707, Rights of Minors, 14 years of age or older.
  • Trainer: refer audience to handout and the handbook template language for all these templates
    Coordination of care expectations and requirements can be found in state law, in regulations applicable to the Medicaid program and in the state’s contact with PIHPs.
    Consumers need to understand or become educated to realize the benefits of coordinating their care, the benefits to themselves and how it allows all of their care providers to provide them with the best treatment and avoid any medication interactions.
    For state service recipients, sharing of information requires a release of information.
    For Medicaid recipients a release of information between Medicaid health providers involved with their care and treatment is not needed. This is because they already agreed to allow the sharing of information between their mental health and other Medicaid service providers when they applied for their Medicaid benefit.
  • Trainer: refer audience to handout and the handbook template language for all these templates
    This requirement can be found in the BBA 438.10 and in the Mental Health code (Section 330.1206, Community mental health services program; purpose; services)
  • Trainer: refer audience to handout and the handbook template language for all these templates
    What good does a book of information, full of terms and acronyms unfamiliar to the reader do? Its just a reference
  • Trainer: refer audience to handout and the handbook template language for all these templates
    Standard # 13 and #14.g.
    See 42CFR (Code of Federal Requirements) 438 for federal requirement
  • Trainer: refer audience to handout and the handbook template language for all these templates
    Language 438.10, Understand and offer.
    The requirements for assistance and accommodation appear in the Medicaid regulations and other Federal laws, the Application for Participation, and the state’s contract with the PIHPs
  • Trainer: refer audience to handout and the handbook template language for all these templates
    Chapter 8 of the Mental Health code describes how much a recipient of public mental health services is required to pay for the services they receive. Based upon a sliding fee determination process, recipients may have to pay between $0.00 and the full cost of services. Medicaid beneficiaries presently have a $0.00 ability to pay but may experience nominal co-pays for some medications
  • Trainer: refer audience to handout and the handbook template language for all these templates
    1996 Michigan Mental Health Code. An individual Plan of Service is written using the Person-Centered planning process. If a new consumer is not offered core information about the process they have a much smaller chance of it being a good plan.
  • Trainer: refer audience to handout and the handbook template language for all these templates
    The assured state rights of each applicant and mental health service recipient are described in Chapter 7 of the Mental Health Code. There are also numerous other rights protection in various Federal laws and regulations. These include but are not limited to HIPAA, the Americans with Disability Act (ADA), the Fair Housing Act, the Individuals with Disabilities Education Act, the Rehabilitation Act and numerous anti-discrimination laws.
  • Trainer: refer audience to handout and the handbook template language for all these templates
    Michigan is in the process of transforming the foundation of our mental health services to a recovery based system. This transformation is referred to in the President’s New Freedom Commission on Mental Health, Goal # 2. This is also referred to in the Michigan Mental Health Commission.
    New enrollees may have no idea that they can recover, the sooner this is mentioned to them the better. Knowing they can recover should instill hope and without hope recovery is very difficult.
  • Trainer: refer audience to handout and the handbook template language for all these templates
    These are descriptions. For the full definition refer to the Medicaid Provider Manual or go to:,1607,7-132-2945_5100-87572--,00.html
  • Trainer: refer audience to handout and the handbook template language for all these templates
  • Customer Services Standards Training by The State of Michigan

    1. 1. CUSTOMER SERVICES STANDARDS TRAINING [Date][Date] [Place][Place]
    2. 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. 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. 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. 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. 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. 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. 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. 9. Background, VI  Therefore, standards are not negotiableTherefore, standards are not negotiable
    10. 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. 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. 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. 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. 14. Standard #1  There shall be a designated unit calledThere shall be a designated unit called “Customer Services”“Customer Services”
    15. 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. 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. 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. 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. 19. Standard #6  The customer handbook shall contain theThe customer handbook shall contain the state-required topicsstate-required topics
    20. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 30. Standard #14.c.  Person-centered planningPerson-centered planning
    31. 31. Standard #14.d.  Self-determinationSelf-determination
    32. 32. Standard #14.e.  RecoveryRecovery
    33. 33. Standard #14.f.  Peer SpecialistsPeer Specialists
    34. 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. 35. Standard #14.h.  Limited English Proficiency (LEP) andLimited English Proficiency (LEP) and cultural competencycultural competency
    36. 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. 37. Standard #14.j: The Public Mental Health System  Structure  Funding  Services  Protections
    38. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 50. Template #1  Confidentiality and family access toConfidentiality and family access to informationinformation
    51. 51. Template #2  Coordination of careCoordination of care
    52. 52. Template #3  Emergency and after-hours access toEmergency and after-hours access to servicesservices
    53. 53. Template #4  GlossaryGlossary
    54. 54. Template #5  Grievance and appealsGrievance and appeals
    55. 55. Template #6  Language accessibility and accommodationLanguage accessibility and accommodation
    56. 56. Template #7  Payment for ServicesPayment for Services
    57. 57. Template #8  Person-centered planningPerson-centered planning
    58. 58. Template #9  Recipient rightsRecipient rights
    59. 59. Template #10  Recovery & ResiliencyRecovery & Resiliency
    60. 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. 61. Template #12  Service authorizationService authorization
    62. 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. 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. 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. 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. 66. Final Questions and Answers