The Health Plan shall ensure equitable access and comparability of benefits across populations and age groups. Coverage shall provide for access to a full continuum of care (including prevention programs) from most to least restrictive in ways which are comparable, though not identical, acknowledging that culturally competent practice provides for variance in individualized care.
- The Health Plan shall not make arbitrary restrictions and limitations in benefit level. For example, in some regions post traumatic stress disorder (PTSD) has been eliminated from the eligible list of treatable disorders. Southeast Asian refugees who suffer disproportionately from PTSD are therefore not eligible for treatment. Cost-effectiveness shall be accomplished through care management and utilization review mechanisms.
- Coverage shall incorporate and integrate innovative treatment modalities, including alternative healers, and primary prevention and health promotion to all levels of care in order to enhance the acceptability and cost-effectiveness of care.
- Coverage shall incorporate services delivered by qualified racial/ethnic mental health specialists when available, or non-minority culturally competent mental health specialists when culturally competent specialists from the appropriate racial/ethnic group(s) are not available.
- Coverage shall incorporate the coordination of services across service agencies and systems serving the consumer in order to ensure cost sharing for consumer services.
- The Health Plan shall provide to consumers and families in their primary language(s) information, community education, and written and oral materials regarding covered services and procedures for accessing and utilizing services. Such information shall be made available through partnerships with community organizations in addition to conventional means of dissemination. Written correspondence or audio presentations regarding eligibility shall be in consumers' and families' primary language(s), with alternative methods of communication also developed and utilized.
- Eligibility and level of care criteria for service provision and/or receiving services shall be developed by or under the guidance of culturally competent bilingual, bicultural providers. These criteria shall be defined primarily by the assessment of behavior and functioning and secondarily by diagnosis, given the limitations of diagnostic systems in cross-cultural applications. Utilization review and eligibility determinations shall be performed by culturally and linguistically competent staff.
- The Health Plan shall provide for consumer choice of individual provider. All providers shall be responsible for comparable levels of service to sponsored (insured) and unsponsored (uninsured) persons.
- The Health Plan shall provide for the needs of both sponsored and unsponsored populations of the four groups and shall provide access for service to unsponsored individuals in proportion to general industry standards and practice.
- The Health Plan shall make provisions in the benefit design for people who leave the Health Plan, including service planning and a transition process to new plans.
- The Public Health Plan shall work with private plans to provide for instances when a privately insured individual becomes uninsured and probably will require services from the Public Health Plan.
- In order to ensure adequate funding for more intensive services, benefits shall include adequate culturally competent risk-adjustment strategies specifically for consumers at-risk for serious and persistent mental illness, emotional disturbance and/or other multiple, long-term service needs.
Recommended Performance Indicators
- Culturally competent eligibility and level of care criteria are formally established.
- Eligibility determinations and service planning are performed by, or under the supervision of linguistically and culturally competent bilingual/bicultural specialists.
- Consumers from the four groups receive direct services provided by or from culturally competent bilingual/bicultural personnel, or by personnel supervised by culturally competent bilingual/bicultural racial/ethnic mental health specialists.
- Consumers receive consumer-friendly bilingual materials on Health Plan benefits.
- Percent of consumers receiving services by traditional healers.
- Treatment plans incorporate individual, familial, and community strengths and appropriate interagency resources.
- Prevention strategies and action plans are implemented.
- Use of flexible funding for consumers from the four groups, comparable across groups.
- Benefit distribution and service provision for consumers from the four groups
Benchmark: Comparable to overall service population.
- Percent of covered consumers who know benefits and how to access them.
Benchmark: 80%, as measured by consumer survey.
- Consumer and family satisfaction with services.
Benchmark: 90% satisfaction.
- Proportionality of racial/ethnic consumer access to full range of benefits.
Benchmark: Comparable to overall service population.
- Focused prevention, education, outreach & services planning for consumers from the four groups.
Benchmark: Increased specialized and preventive services to at-risk consumers.