Procedure - Beneficiary Rights

Responsible Party ​

Action Required​​

​BHSD Administration

  1. Acquire and maintain written contracts with enough providers to make sure that all enrollees and other service recipients who qualify for specialty mental health services can receive them in a timely manner.

  2. Makes sure providers are qualified to deliver behavioral health services and that providers are in compliance with what services they agreed to cover.

  3. Makes certain covered services are adequate in amount, duration, and scope to meet the needs of the Medi-Cal eligible individuals it serves. This includes making sure the MCP’s system for authorizing payment for services is based on medical necessity and uses processes that ensure fair application of the medical necessity criteria.

  4. Ensures that its providers perform adequate assessments of individuals who may receive services and work with the individuals who will receive services to develop a treatment plan that includes the goals of treatment and the services that will be delivered.

  5. Does not prohibit informed consent or activities that promote the dignity of beneficiaries.

  6. Provide for a second opinion from a qualified health care professional within the MCP’s network, or one outside the network, at no additional cost to the individual.

  7. Coordinate the services it provides with services being provided to an individual, including their primary care provider. Ensures that the privacy of each individual receiving services is protected as specified in federal rules on the privacy of health information.

  8. Provides timely access to care, including making services available 24-hours a day, 7 days a week, when medically necessary to treat an urgent or emergent behavioral health condition.

  9. Participates in the State’s efforts to promote the delivery of services in a culturally competent manner to all individuals, including those with limited English proficiency and diverse cultural and ethnic backgrounds.

  10. Provides and requires provider workforce education, training, and development related to cultural competency on an annual basis.

  11. Ensures treatment is not adversely affected as a result of individuals using their rights.

  12. Covers medically necessary services out-of-network in a timely manner, if the MCP doesn’t have an employee or contract provider who can deliver the services.

  13. Ensures individuals don’t pay anything extra for seeing an out-of-network provider.

  14. Provides language services and written materials free of charge to beneficiaries.

BHSD Quality Assurance Department ​

  1. Conducts site certifications every 3 years for MCP entities to determine if a provider is in compliance with individual rights and regulations.

  2. Materials developed and distributed by BHSD to be given to individuals will meet readability, font size, and threshold language requirements in addition to being field-tested in advance of distribution.

  3. Reviews BHSD Beneficiary Handbook on an annual basis and makes changes as needed. The content of the handbook and any changes need to be consistent with State and Federal requirements.

  4. Updates and distributes the BHSD Beneficiary Handbook to all Medi-Cal beneficiaries and providers at least 30 days prior to a change.

  5. In conjunction with the Business Office, updates Provider List when there is a change in scope of behavioral health services and on a monthly basis. The Provider List will include all required information in accordance with the State and Federal requirements.

  6. Posts BHSD Beneficiary Handbook and Provider List on BHSD Website. https://bhsd.sccgov.org/home

  7. Will update State Advance Directive changes within 90 days of implementation of the change. a. Will notify providers of State changes.

  8. Maintains TTY information about materials on the BHSD Website. https://bhsd.sccgov.org/home

  9. Will make a good faith effort to provide written notice of termination of the contracted provider within 15 calendar days to each enrollee that had received services from or was seen on a regular basis by the terminated contract provider.

  10. Process and monitor grievances, appeal, expedited appeals filed with BHSD.

  11. Oversees Notices of Adverse Benefit Determinations to ensure providers cannot request enrollee disenrollment for:

    a. Change in enrollee health status​

    ​b. Utilization of medical services

    c. Diminished capacity

    d. Uncooperative or disruptive enrollee behavior is secondary to special needs.

  12.       ​Report performance data which includes but is not limited to:

    a. Enrollment and disenrollment data ​

    ​b. Grievance and Appeal Logs

    c. Provider Compliant and Appeal Logs

    d. Timely Access Logs.

Providers​

  1. Facilities meet American’s with the Disability Act physical access and reasonable accommodations requirements.

  2. Has accessible equipment for beneficiaries with physical or mental disabilities.

  3. Provide each beneficiary with all BHSD notices and informational materials in a manner and format that is easily understood.

    a. In regular and large font​

    ​b. In Threshold Languages

    c. Use auxiliary aids such as TTY and American Sign Language

    d. Make oral interpretation services available and provide those services free of charge to each potential beneficiary and beneficiary​.

  4. Makes available the BHSD Beneficiary Handbook and Provider List in all threshold languages.

  5. Change out Guide to BHSD Beneficiary Handbook and Provider Lists within 30 days of BHSD notification of changes.

  6. Displays County Grievance, Appeal, and Expedited Appeal processes in all threshold languages in site waiting areas.

  7. Has pre-paid addressed envelopes, grievance, appeal, and expedited appeal forms readily available in site waiting areas.

  8. Ensures individuals receive Voter Registration services, maintains separate records that individuals served by the program have been offered the opportunity to register to vote per BHSD Voter Registration Policy #412-319.

  9. Provide Advance Directive training regarding provider policies and procedures related to advance directives.

  10. Provide Advance Directive information to individuals when they first receive services and on request.

  11. Places Advance Directives in the client record and prominently note enrollee has an Advance Directive.

  12. Participates in annual cultural competency trainings.

  13. If a client requests a Second Opinion:

    a.  For Mental Health Services, contact the Call Center at (800) 704-0900 to arrange a referral for a second opinion.

    ​b.  For Substance Use Treatment, the provider or the beneficiary notifies the Beneficiary Line (408) 792-5666 to arrange a referral for a second opinion.

  14. Prepares and tests any proposed written materials for readability, threshold languages, and font size prior to distribution.

  15. Measures and meets timely access standards.

  16. Issues a formal valid termination notice 30 days prior to BHSD contract termination, if applicable.

    a. If closing:

    I. Submit beneficiary records to BHSD.

    II. Arrange for electronic record access for BHSD.

  17. Works with BHSD Contract Monitors to transition beneficiary care.​

Clinical or Medical Staff​

  1. Provide informed consent discussion that covers:

    a. Nature of client’s condition

    b. Type, range of frequency, amount (including PRNs), method (oral or injection), and duration of taking medication.

    c. Reason for treatment or services, including the likelihood of improving or not improving without such intervention.

    d. Probable side effects of any medications known to commonly occur, any particular side effects likely to occur with the individual, and other possible side effects of long-term​ usage.

    e. The type and frequency of other recommended treatment interventions including but not limited to case management services, psychiatry appointments and group or individual therapy

    f. Reasonable alternative treatments, if any

    g. The right to participate in decisions regarding their care.

    h. The right to refuse treatment.

    i. The right to withdraw consent at any time for any reason.

    j. The right to give written (signed) or oral consent to treatment.

  2. For second opinion requests:

    a.  For Mental Health, conduct assigned requests for a second opinion through a face-to-face evaluation within 30 days of referral.

    b.  For Substance Use Treatment services, conducts a face-to-face assessment within 5 days of receipt of referral.

  3. Assists in completion or links to entities that can complete Advance Directive on enrollee request.

  4. Perform enrollee assessment for those who will receive services in order to develop a treatment plan with the enrollee that includes goals of treatment and services to be delivered.

    a. Obtain signature of the individual, individual’s legal representative or conservator or the individual’s parent or legal guardian for children and adolescents

    b. Document if the individual does not or cannot sign the plan in a progress note.

    c. Provide individual/family with copies of the plan.

  5. Update assessment and plan information when the individuals' condition changes, new needs emerge and when renewal is required due to documentation timelines.

  6. Links enrollees to Long Term Support Services (LTSS) if they express a desire to receive LTSS or they appear to qualify for LTSS.

Call Center​

  1. Maintains a toll-free number offering assistance to help beneficiaries understand the managed care plan and can assist in making enrollment decisions.

  2. Ask individuals with limited English proficiency (LEP), limited reading proficiency, and those with other language and communication barriers their preferred language and refers individuals to a provider that can meet these communication needs.

  3. Offer beneficiaries a choice of provider and change of provider.

BHSD Division Director or designee​

  1. Ensures appropriate written notice of termination is provided to the Department Director and Board of Supervisors.

  2. Provides properly written notifications are provided to each affected beneficiary within 15 calendar days of notification of termination of a contracted provider.

​BHSD Contract Monitor

  1. Coordinates the transition of the beneficiary to an alternative program (if applicable).

  2. Notifies the Call Center and other referring entities of the Program (or Agency) closure so that future referrals cease, referrals in progress are redirected to other programs.

  3. Meet with the Contractor:

    a. Review the number of clients to be closed and/or transferred.

    b. Utilize BHSD electronic record system to identify the current open caseload.

    c. Review the 30, 60, 90-day reports to identify potential case closures.

  4. Help identify which programs or agencies in which to transition the clients.

  5. Facilitate transition meetings with BHSD contractors if needed.

  6. Track transition progress made by BHSD contractors.

  7. Secure any County equipment and inventory items belonging to BHSD.

  8. If the program and the agency is closing:

    a. Identify if there are any paper charts.

    b. Paper charts belong to BHSD when a program and agency close. Charts will need to be stored at iron Mountain through BHSD.

    c. Electronic records in agency’s HER will need to be collected by BHSD.

  9. If only the program is closing but the BHSD contractor has a contract with BHSD:

    a. BHSD contractor will maintain the client records and make them available to clients upon request within the timeframe designated for storage of records.

  10. Ensure BHSD contractor has closed all cases in the relevant BHSD electronic records system after proper transition of th​e clients.

  11. Submit a UCCAR to terminate the U-code once billing for services is completed (typically 3-6 months after termination).

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