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Policy Report: Civil Commitment Under
Medicaid Managed Care
Executive Summary
This report presents findings from an exploratory study of the
relationship between Medicaid managed behavioral health
care and the use of inpatient civil commitment. Data collection
methods included a literature review of Medicaid managed behavioral
health care, civil commitment, and the relationship between the
two; in-depth telephone interviews with policy experts; and interviews
with stakeholder representatives in nine States to ascertain how civil
commitment is handled in each State’s Medicaid managed care contract,
and any specific results that were observed. The interview questions
focused on the following issues:
Has the State addressed the issue of civil
commitment in its Medicaid managed care
contract? If so, does the contract clearly
specify:
Although some information was gathered
about relevant contract provisions for each of
the nine study sites, only four States-
Colorado, Iowa, Wisconsin, and Minnesota-
were able to offer a comprehensive view of the
issue. Case studies for these four States were
thus developed and included in this report.
Clearly, States vary considerably in terms of
their Medicaid managed care financing
arrangements, their civil commitment statutes
and patterns of use, and the manner in which civil commitment issues are addressed in
Medicaid managed care contracts.
Nevertheless, the case study interviews did
suggest some relatively consistent observations
on the probable relationship between
Medicaid managed care contract provisions
and the use of civil commitment:
- Increased use of court-ordered treatment
may occur if an MCO contract does not
address the issue of who is fiscally responsible
for costs associated with civil commitment.
The absence of clear contract
provisions may create incentives for the
MCO to use civil commitment as a way
to shift costs to the State mental health
authority or to counties. Some MCOs rely
on principles of private insurance law to
deny the medical necessity of court-ordered
services automatically. Others rely
on the Medicaid IMD exclusion to deny
payment for court-ordered services provided
in State hospitals. Contracts that
anticipate and address potential cost-shifting
may prevent an increase in the frequency
of civil commitment.
- Collaboration between the judiciary and
the MCO may reduce the incidence of
court orders to inpatient settings. Many
judges, with limited knowledge of treatment
options within the community, may
routinely order civilly committed individuals
to inpatient settings, including settings
(such as State hospitals) outside the
MCO’s provider network. Communication
between the courts and the MCO
often results in treatment in less restrictive
settings and also allows the MCO to
better manage treatment costs.
- Systems that overly restrict access to services
may increase the use of civil commitment
as a way to obtain treatment. One
such restrictive policy is the use of a narrow "medical model" definition of medical
necessity. Such a definition may leave
the MCO too much latitude to deny payment
for services required by persons
with serious mental illness. Medicaid
managed care contracts can address policies
related to treatment accessibility so
that needed services can be obtained
without resorting to court orders.
- A comprehensive system of community-based
treatment and supports may reduce
the need for civil commitment. The types
of supportive services required to enhance
the probability of an individual’s stable
functioning in community settings are
well established, but are not always
included in Medicaid managed behavioral
health care programs. (In the absence of
such services, the condition of a person
with mental illness may be more likely to
worsen and lead to civil commitment.)
Contracts that require the MCO to develop
strong community supports may result
in a system more responsive to the consumers’
needs, thereby reducing the need
for civil commitment.
The dearth of quantitative data from the
study sites limited the ability to draw more
comprehensive conclusions about the relationship
between Medicaid managed care and
civil commitment. Specifically, most States do
not keep records of the number of civil commitment
orders made for persons with mental
illness. Thus, one of the key policy suggestions
to emerge from this study is that States
should track this information-for inpatient
as well as outpatient settings-particularly if
they are implementing a Medicaid managed
behavioral health care system. Only with
valid and reliable longitudinal data will
future research be able to identify clear trends
in the use of civil commitment procedures.
1 An institution for mental disease is defined as any
facility with 16 or more beds devoted exclusively
to the delivery of psychiatric services. Under the
Federal Medicaid statutes, Medicaid funds cannot
be used to pay for IMD services for adults between
the ages of 21 and 64. The intent of this provision,
enacted in 1965, was to ensure that the States’
traditional responsibility for funding State mental
hospitals is not shifted to the Medicaid program.
However, States may opt to cover IMD treatment
for individuals under 21 years of age or over 64
years of age.
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