What states allow Medicaid to cover court order psychiatric services, what states do not allow Medicaid to cover court order psychiatric services, and what does ACA say about this?
Implications of the Affordable Care Act's Medicaid Expansion on Low-Income Individuals on Probation (Marsha Regenstein and Lea Nolan, George Washington University, 2014)
“Though the ACA will provide Medicaid coverage or subsidies for private health insurance marketplace plans to those who are determined to be eligible, questions arise as to whether mental health and/or substance use treatment services will be covered under these programs if they are court ordered, or merely recommended, as opposed to being referred by a certified Medicaid provider.
“The Medicaid program has long debated this issue. The Centers for Medicare and Medicaid Services (CMS) has never issued any ruling that definitively addresses whether court-ordered treatments must be covered by state Medicaid programs. Some states and jurisdictions have opted to allow payment for court-ordered services, while others have explicitly refused such payments. However, since there is no federal guidance prohibiting coverage of court-ordered services, states are free to include them among their covered benefits.”
Medicaid Third Party Liability & Coordination of Benefits (Medicaid.gov)
“It is common for Medicaid beneficiaries to have one or more additional sources of coverage for health care services. Third Party Liability (TPL) refers to the legal obligation of third parties (e.g., certain individuals, entities, insurers, or programs) to pay part or all of the expenditures for medical assistance furnished under a Medicaid state plan. By law, all other available third party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid. States are required to take all reasonable measures to ascertain the legal liability of third parties to pay for care and services that are available under the Medicaid state plan…
“Coordination of Benefits (COB) refers to the activities involved in determining Medicaid benefits when an enrollee has coverage through an individual, entity, insurance, or program that is liable to pay for health care services. Individuals eligible for Medicaid assign their rights to third party payments to the State Medicaid Agency.
“Examples of third parties which may be liable to pay for services: … Court-ordered health coverage.”
The Affordable Care Act and County Jails (National Association of Counties, 2015)
See “Will Medicaid or Marketplace insurance plans pay for court-ordered services?”:
“If an eligible individual is court-ordered to receive any of these covered benefits, his or her insurance plan will decide if it is a “medical necessity.” The definition of medical necessity is not spelled out in the ACA; Medicaid and Marketplace insurers define the term on their own, often based on state laws or regulations. County jails should research their state regulations on medical necessity in order to best advocate for reimbursement where appropriate. Additionally, if a judge orders treatment at a non-certified provider, Medicaid and Marketplace plans will not cover that cost.”
Civil Commitment under Medicaid Managed Care (Substance Abuse and Mental Health Services Administration, 2000)
New York: Medicaid Managed Care (MAMC) and Family Health Plus (FHPlus): Summary of General Rules and Special Policies
“Court Orders: MAMC and FHPlus plans provide court ordered benefit package services. Managed care plans must accept the condition of the court order and may not apply their own medical necessity or prior approval review criteria. (e.g. the plan must honor court ordered length of stays, levels of treatment and specific provider. FHPlus plans are only responsible for services up to the FHPLus CD benefit limits) CAUTION: Providers should encourage the court to provide your facility with a written order that is signed by the Judge.”
New York: Court Orders and Medicaid Managed Care and Family Health Plus Enrollees
Drug Treatment, Managed Care and the Courts (Center for Court Innovation, 2004)
“In New York, courts received an important tool from the Legislature, which, in the mid-1990s, adopted a bill requiring Medicaid managed care plans to pay for court-ordered treatment. The law covers all Medicaid managed care recipients, which, along with traditional fee-for-service Medicaid, make up the majority of New York’s drug court clients.”
Journal article citations
Code of Colorado Regulations, 10 CCR 2505-10 8.300 (Medical Assistance)
8.300.4 Non-Covered Services: The following services are not covered benefits: … Court-ordered psychiatric Inpatient care which does not meet the Medical Necessity criteria established for such care by the Department’s utilization review vendor or other Department representative.
MDwise Health Indiana Plan Member Handbook (undated)
“The following services are not covered under the Healthy Indiana Plan: … Court ordered testing or care, unless medically necessary.”
Iowa Administrative Code, 441 IAC 151.21 and 22, Human Services Departments – Juvenile Court Services Directed Programs
“Medicaid. The department shall maximize the use of funds that may be available from the Medicaid program, including coverage for early and periodic screening, diagnosis, and treatment and for psychiatric medical institutions for children (PMIC), before requesting assistance through the court-ordered services fund. However, medical cost sharing for the one-time payment per court order of a deductible amount or a coinsurance amount for treatment specified in a court order is an allowable expense that may be paid through the court-ordered services fund when insurance or Medicaid is then available to pay the remainder of the cost.”
From Kentucky Administrative Regulations, Title 907, Cabinet for Health and Family Services Department for Medicaid Services:
907 KAR 10:016. Coverage provisions and requirements regarding inpatient psychiatric hospital services, Sec. 6, Other limitations and exclusions (Amendment, Administrative regulation going through regulation amendment process)
“(3) The Medicaid Program shall not reimburse for a court-ordered psychiatric hospital admission unless the department determines that the admission meets the criteria established in Section 3(1) of this administrative regulation.”
907 KAR 17:020. Managed care organization service and service coverage requirements and policies.
“Section 13. Court-Ordered Psychiatric Services. (1) An MCO [managed care organization] shall:
(a) Provide an inpatient psychiatric service to an enrollee under the age of twenty-one (21) or over the age of sixty-five (65) who has been ordered to receive the service by a court of competent jurisdiction under the provisions of KRS Chapters 202A or 645;
(b) Not deny, reduce, or negate the medical necessity of an inpatient psychiatric service provided pursuant to a court-ordered commitment for an enrollee under the age of twenty-one (21) or over the age of sixty-five (65);
(c) Coordinate with a provider of a behavioral health service the treatment objectives and projected length of stay for an enrollee committed by a court of law to a state psychiatric hospital; and
(d) Enter into a collaborative agreement with the state-operated or state-contracted psychiatric hospital assigned to the enrollee’s region in accordance with 908 KAR 3:040 and in accordance with the Olmstead decision.
(2) An MCO shall present a modification or termination of a service referenced in subsection (1)(b) of this section to the court with jurisdiction over the matter for determination.
(3)(a) An MCO behavioral health service provider shall:
1. Participate in a quarterly continuity of care meeting with a state-operated or state- contracted psychiatric hospital;
2. Assign a case manager prior to or on the date of discharge of an enrollee from a state-operated or state-contracted psychiatric hospital; and
3. Provide case management services to an enrollee with a severe mental illness and co-occurring developmental disability who is discharged from a:
a. State-operated or state-contracted psychiatric hospital; or
b. State-operated nursing facility for individuals with severe mental illness.
(b) A case manager and a behavioral health service provider shall participate in discharge planning to ensure compliance with the Olmstead decision.”
Louisiana Administrative Code, LAC 50:VII.30303 and 10305
“Court ordered admissions do not guarantee Medicaid vendor payment to a facility. A court can order that a client be placed in a particular facility but cannot mandate that the services be paid for by the Medicaid program.”
Code of Massachusetts Regulations, Division of Medical Assistance, Psychiatric Inpatient Hospital Services, 130 CMR 425.406 and 410
“Members under age 21 must be prescreened by a screening team or be admitted under court order...”
From New Jersey Administrative Code (attached)
Services available and unavailable to beneficiaries eligible for NJ FamilyCare-Plan D and Plan D for adults , NJAC 10:49-5.7 (2015)
“Services not covered include, but are not limited to… Court ordered services.”
Services available to beneficiaries eligible for NJ FamilyCare-Plan I, N.J.A.C. 10:49-5.10 (2015)
“Services which shall not be covered include, but shall not be limited to: … Court ordered services.”
Benefits not provided for NJ FamilyCare-Plan D enrollees , NJAC § 10:74-3.8
“The following services shall not be covered for NJ FamilyCare-Plan D participants either by the MCO or the Department… Court-ordered services.”
Texas Medicaid Provider Procedures Manual
Services, Benefits, Limitations, and Prior Authorization - Inpatient Psychiatric Services : 3.4.7 Court-Ordered Services
Psychiatric services for hospitals: Prior reauthorization requirements
“For clients who are 20 years of age and younger, initial admission to a state psychiatric facility or freestanding psychiatric facility may be prior authorized through CCIP for a maximum of five days based on Medicaid eligibility and documentation of medical necessity. Court-ordered services are not subject to the five-day admission limitation.”
Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), and Licensed Professional Counselor (LPC) : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.1 Prior Authorization : 188.8.131.52 Prior Authorization for Court-Ordered and Department of Family and Protective Services (DFPS)-Directed Services
Aetna Better Health: Star and CHIP Provider Manual - Bexar and Tarrant Service Area — September 2012
“Court Ordered Commitments A “Court-Ordered Commitment” means a confinement of a Member to a psychiatric facility for treatment that is ordered by a court of law pursuant to the Texas Health and Safety Code, Title VII, Subtitle C. We are required to provide inpatient psychiatric services to Members under the age of 21, up to the annual limit, who have been ordered to receive the services by a court of competent, jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, related to Court-Ordered Commitments to psychiatric facilities. Aetna Better Health will not deny, reduce or controvert the medical necessity of inpatient psychiatric services provided pursuant to a Court-Ordered commitment for Members under age 21.”
Magellan Behavioral Health Providers of Texas, Inc. Provider Handbook Supplement for Texas Medicaid (STAR) and CHIP Programs
“Magellan is subject to all state and federal laws and regulations relating to court-ordered commitments, and will provide services to CHIP and STAR members within regulatory requirements.”
“Magellan will provide inpatient psychiatric services to members fewer than 21 years of age, up to the annual limit, who have been ordered to receive the services by a court of competent jurisdiction, under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, related to Court-Ordered Commitments to psychiatric facilities.”
Vermont Medicaid Non-Emergency Medical Transportation (NEMT) Procedure Manual (July 1, 2014)
Court-Ordered Services: Transportation may be authorized if a member is mandated by a court to attend a service such as counseling or other form of therapy, as long as the appointment is both a normally-covered Medicaid service and the provider is participating with Vermont Medicaid. Normal NEMT rules apply with regard to distance, available vehicles, and the possible need for a prior authorization
Rate information for billing for services provided by the mental health institutes (Wisconsin Division of Mental Health and Substance Abuse Services, 2014)
“Medicaid (MA) will not pay for court-ordered evaluation or treatment services provided to a juvenile under chapter 938 because these services are not considered to be medically necessary (the same as for services provided under the adult criminal code in sections 971.14 and 971.17, Wis. Stats.). Therefore, the county that orders evaluation or treatment services under chapter 938 is responsible for payment for these services…”