Benefit Design

Standard

The Health Plan should ensure equitable access and comparability of benefits across populations and age groups. Coverage should provide for access to a full continuum of care, from most to least restrictive in ways which are comparable, though not identical, acknowledging that culturally competent practice provides for variance in individualized care.

Implementation Guidelines

• The Health Plan should not make arbitrary restrictions and limitations in benefit level. Cost-effectiveness should be accomplished through care management and utilization review mechanisms.

• Coverage should incorporate and integrate innovative treatment modalities, including alternative healers, in order to enhance the acceptability and cost-effectiveness of care.

• Coverage should incorporate services delivered by qualified Latino Mental Health Specialists (LMHS) and supervision by LMHS’s for practitioners who do not qualify as such, but who are serving Latinos.

• Coverage should 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 should provide information, community education and written materials to consumers and families regarding covered services and procedures for accessing and utilizing services in their primary language(s). Such information should be made available through partnerships with community organizations in addition to conventional means of dissemination.

• Eligibility and level of care criteria for service provision and/or receiving services should be developed by or under the guidance of Latino Mental Health Specialists. These should 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 should be performed by culturally and linguistically competent staff.

• Written correspondence regarding eligibility should be in consumers’ and families’ primary language(s) with alternative methods of communication also developed and in place.

• The Health Plan should provide for consumer choice of provider. All providers should be responsible for comparable levels of service to sponsored and unsponsored persons.

• The Health Plan should provide for the needs of both sponsored and unsponsored Latino populations and should provide for unsponsored access in proportion to general industry standards and practice, e.g., 75% to 25% ratio.

• The Health Plan should make provisions in the benefit design for people who leave the Health Plan, including service planning and a transition process to new plans.

• In order to ensure adequate funding for more intensive services, benefits should include a subcapitation approach or other adequate risk-adjustment strategies specifically for consumers at-risk for serious and persistent mental illness, emotional disturbance and/or other multiple, long-term service needs.

• The Health Plan should ensure coordination with private plans from which unsponsored lives may emanate.

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, LMHS.

• Latino consumers receive direct services provided by Latino Mental Health Specialists, or from personnel supervised by LMHS.

• Consumers receive bilingual materials on Health Plan benefits.

• Percent of consumers receiving services by cultural healers.

• Treatment plans incorporate services from multiple agencies.

Recommended Outcomes

• Benefit distribution and service provision for Latino consumers
  
  Benchmark: Comparable to overall service population

• Percent of Latino covered consumers who know benefits and how to access them
  
  Benchmark: 100%, as measured by consumer survey

• Consumer and family satisfaction with services
  
  Benchmark: 90% satisfaction

• Proportionality of Latino consumer access to full range of benefits
  
  Benchmark: Comparable to overall service population

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