How Do I Find Out About Services?
You may call or visit any of our offices to receive information and help in obtaining services. A receptionist may ask you a few questions, schedule an appointment, or refer you to a caseworker for assistance. Routine appointments are scheduled within seven (7) days.
Who Is Eligible?
Any person in the three-county area with mental health, behavioral health or mental retardation issues or an infant/toddler with developmental disabilities is eligible for services provided by the Carbon-Monroe-Pike MH/MR Program.
No one is denied service because of inability to pay. Services are available without regard to race, color, sex, creed, age, disability, handicap, ancestry, or national origin.
The agency's goal is to assure that persons with mental disabilities can receive any service necessary to enhance their involvement in the community and to enable them to remain and function in the community in the least restrictive setting. Families are encouraged to contact their local MH/MR office to discuss the programs available to meet the needs of a family members with disabilities.
What is Self-Determination?
The Carbon-Monroe-Pike MH/MR Program is committed to promoting the philosophy and practices of self-determination through a program model referred to as individual supports. Consumers and their families access services through a person-focused planning process which emphasizes choice, consumer shopping, and selection of providers/services. Budgets are derived from these plans which essentially tie funding to individuals.
What Happens When I Call for Services?
A case manager/service coordinator will ask you a few questions to determine what needs you or your family member may have and will check on your insurance coverage and other financial information. If your call is urgent, your crisis will be handled within the hour. See the numbers on the inside cover for 24-hour availability of mental health crisis workers. Otherwise, you or your family member will be scheduled within 7 days of your call or in the next 24 hours, depending on your need.
What If I Can't Make It to My Appointment?
If you cannot keep your appointment, please call as soon as possible (at least 24 hours in advance) to cancel. Your time can be used by someone else seeking services.
What Happens When I Come In?
At your first appointment you will meet with a case manager/service coordinator to discuss your concerns, needs, resources, and have an intake interview completed for you or your family member. You will also find out about program availability, costs, and your particular benefit package. There is no charge for this visit.
You and your case manager/service coordinator will develop an individual service plan which recommends what type(s) of services would best meet your needs and choices. Natural and community resources are preferred to formal services whenever possible. Your assigned case manager/service coordinator is responsible for arranging and authorizing services for you and knowing your progress, needs, and issues.
What is an Authorization?
This is an approval by MH/MR for you to receive a specified type and number of services at the program you have selected based on your level-of-care need and the service providers' availability. If you believe you have been denied a medically necessary service, you may file a grievance.
What are the Limitations or Exclusions?
1. A psychiatrist or other physician (or a psychologist in some cases) must make a determination of medical necessity for any medically based mental health services;2. All MH/MR services are authorized only to the extent of the funding available.
3. Medical Assistance coverage confers an entitlement to covered services when determined to be medically necessary.
How Much Will Services Cost?
Costs are based on the type of service you receive, your insurance coverage, and the amount you must pay per month (called your liability). This is calculated according to a formula developed by the state. There is no charge for most of the services within the mental retardation or early intervention systems. Your health benefit plan (insurance) may cover the costs of some services.
Your liability is determined on the first visit. Therefore, YOU WILL KNOW YOUR MAXIMUM COSTS BEFORE SERVICE BEGINS. ELIGIBILITY, BENEFITS, AND FINANCIAL LIABILITY MUST BE DETERMINED BEFORE SERVICES ARE BEGUN. Information which should be brought to the first intake includes:
1. ACCESS Card
2. Medicare Card
3. Medical Assistance Card
4. Amount of benefits (such as Social Security or SSI)
5. Other health insurance or HMO cards
6. Three (3) current pay stubs (both spouses)
7. Medical bills incurred during the current year that were not covered by medical benefits
8. Prior year tax return forms
9. Real estate tax receipt
10. School tax receipt
Persons with ACCESS or Medical Assistance cards may not be charged for eligible services.
Past due accounts are turned over to a collection agency. Consumers with past due accounts may not continue to receive services.
What Types of Insurance Coverage are there?
Managed Care Organization or Health Maintenance Organization (MCO /HMO). Health coverage which requires the user to receive services through its network. Services occur via referral and have to be preauthorized. Not all MCOs will subsidize services via MH/MR providers. You will be required to use a provider in the MCO's network.
Third-Party Insurance. Includes private insurances and those purchased by employers for their employees/dependents (for example, Aetna, Blue Cross/Blue Shield). If MH/MR and/or a provider has an agreement with your particular insurance company, we can bill for any services included in your plan to the extent of the plan coverage.
Medicare. A government-sponsored health care plan which covers some behavioral health services for elderly and disabled people. The amount and frequency of the services may be limited, and you are responsible for a deductible and co-pays.
Medicaid or Medical Assistance (MA, ACCESS). A government-sponsored health care plan for people with certain income limits which covers you for specific physical and behavioral health services. There may be a deductible and co-pay depending on your income and the required services. MH/MR and all its providers accept MA as payment for in-plan medical services.
Children's Hospital Insurance Program (CHIP). A state plan of health care benefits for children of families whose income exceeds MA limits who have no other coverage. It covers children from birth until their 19th birthday. They must be U.S. citizens or lawful aliens and have resided in Pennsylvania for at least 30 days (except for newborns). Call 1-800-986-KIDS to apply if your children have no health coverage.
Special Pharmaceutical Benefits Program (SPBP). If you have a DSM IV diagnosis for schizophrenia and are prescribed an atypical antipsychotic, you may be eligible for medication coverage. Ask your case manager/service coordinator about this special program or call 1-800-922-9384.
What if I do not have Health Insurance?
Carbon-Monroe-Pike MH/MR Program provides payment for services based on a consumer's eligibility and liability when there are no other sources of payment for services which have been determined to be medically necessary. It contracts with a network of providers who will provide you with authorized services for which MH/MR is billed. You will be obligated to pay the provider your calculated monthly liability as your portion of the cost. This amount may be as low as zero, depending on your income and the types of services to be received.
What are Waiver Programs?
Many mental retardation or early intervention services are paid for with state and federal matching funds under a waiver allowing services to be provided in the community. Your case manager/service coordinator will explain the requirements and eligibility for waiver services.