Medicaid outpatient behavioral health therapy visit cap removed effective 10/01/2017

Effective October 1, 2017, all Medicaid plans will have the 20 visit maximum cap lifted for outpatient behavioral health therapy services. 

Specifically, the Michigan Department of Health and Human Services has mandated plans operationalize this change on the MDHHS fiscal year, starting on October 1, 2017. Medicaid benefits through Priority Health renew on a calendar year basis rather than following the MDHHS fiscal schedule. However, this change will need to be made effective prior to the new calendar year. 

Priority Health or local CMH?

Priority Health is responsible for providing outpatient behavioral health therapy services for members with mild to moderate mental health needs. Members with a severe mental illness, serious emotional disturbance (adolescents) or those with a developmental disability are more appropriately served and the responsibility of the local Community Mental Health (CMH) provider. All levels of substance abuse treatment services continue to be the responsibility of CMH providers.

Severity determination process

Currently, members call our Behavioral Health team to request authorization for outpatient services. Some providers submit authorization requests directly to Priority Health to determine if the member's needs are mild to moderate or more severe. This process will remain the same until 12/31/2017.

Beginning on January 1, the Behavioral Health team will be changing this process to allow for initial assessments to occur without prior approval. Providers will be instructed to submit authorization requests after an initial assessment is completed and a determination made that the member's clinical needs for services are mild to moderate.

Additional information about these changes will be communicated prior to January 1, 2018.

High-volume visits may require diagnostic reviews

The Behavioral Health team is establishing a process to conduct a diagnostic review of members that have a high volume of outpatient therapy visits to determine if needs are beyond mild/moderate and require more intensive specialized therapy services from local CMH providers.