The Health Plan shall ensure equitable access and comparability of benefits across APIA 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 that disproportionately affect APIA consumers (e.g., in some regions, post traumatic stress disorder (PTSD) has been eliminated from 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 to APIA populations.
- Coverage shall incorporate services delivered by qualified APIA Mental Health Specialists when available and appropriate for the consumer, or culturally competent Mental Health Specialists when APIA specialists are not available.
- Coverage shall incorporate the coordination of services across service agencies and systems serving the APIA consumer in order to ensure cost sharing for consumer services.
- The Health Plan shall provide information, community education, and written and oral materials to APIA consumers and families regarding covered services and procedures for accessing and utilizing services in their primary language(s). Such information shall 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 shall be developed by or under the guidance of APIA culturally competent Mental Health Specialists. These 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 APIA culturally and linguistically competent staff.
- Written correspondence or audio presentation regarding eligibility shall be in consumers’ and families’ primary language(s) with alternative methods of communication also developed and documented.
- The Health Plan shall provide for APIA consumer choice of provider. All providers shall be responsible for comparable levels of service to sponsored (insured) and unsponsored persons.
- The Health Plan shall provide for the needs of both sponsored and unsponsored APIA populations and shall provide for unsponsored access in proportion to general industry standards and practice.
- The Health Plan shall make provisions in the benefit design for APIAs 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 shall include adequate risk-adjustment strategies specifically for APIA consumers at-risk for serious and persistent mental illness, emotional disturbance and/or other multiple, long-term service needs.
- The Health Plan shall ensure coordination with private plans to plan for those instances when an APIA sponsored participant becomes unsponsored and is considered for services under the Health Plan.
- The Health Plan shall include prevention and mental health promotion strategies that target APIA populations, across all levels of care.
Recommended Performance Indicators
- APIA Culturally competent eligibility and level of care criteria are formally established.
- Eligibility determinations and service planning are performed by, or under the supervision of APIA culturally competent Mental Health Specialists.
- APIA consumers receive direct services provided by, or from personnel supervised by APIA culturally competent Mental Health Specialists.
- Consumers receive APIA consumer-friendly bilingual materials on Health Plan benefits.
- APIA consumers receive services by cultural healers.
- APIA treatment plans incorporate individual, familial, and community strengths and appropriate interagency resources.
- Prevention strategies and action plans targeting APIA populations are implemented.
- Use of flexible funding for APIA consumers comparable across to others.
- Benefit distribution and service provision for APIA consumers.
Benchmark: Comparable to overall service population
- Percent of covered APIA consumers who know benefits and how to access them.
Benchmark: 80%, as measured by consumer survey
- APIA consumer and family satisfaction with services.
Benchmark: 90% satisfaction
- Proportionality of APIA consumer access to full range of benefits.
Benchmark: Comparable to overall service population
- Focused prevention, education, outreach & services planning for APIA consumers.
Benchmark: Increased specialized and preventive services to at-risk consumers