Behavioral Health and ARTS

Medallion and CCC Plus Plans

Many individuals struggle with mental health conditions such as depression, anxiety, or other mental health issues. Substance use may also be a factor. Behavioral health services offer many types of treatments for those with a mental health or substance use disorder.

These behavioral health services do their best to help people live satisfying and independent lives in their communities. Services range from outpatient counseling to hospital care. These include day treatment and crisis services and can be provided in your home or in the community, over a short or long time frame. All services are performed by qualified individuals and organizations.

ABA services are designed to enhance communication skills and decrease maladaptive patterns of behavior through data collection.

These services:

• Are available to members under 21 years of age.
• Should make sure member’s family or caregiver is trained to support the member in the home and community using the skills learned while actively participating in services.

ABA may not be combined with Intensive In-home Services, Mental Health Skill-building Services, Psychological Rehabilitation, Multisystemic Therapy, Functional Family Therapy, Partial Hospitalization Program or Assertive Community Treatment

Accessing Medicaid Behavioral Health Services

To access Behavioral Health Services, please reach out to Behavioral Health member services at 1-757-552-7174 for Optima Family Care members, 1-757-552-7580 for Optima Health Community Care members, or call the toll free number at 1-888-946-1168 for both Optima Family Care and Optima Health Community Care members.

How to Access Non-Emergency Transportation Services

Transportation Services Covered by Optima Health

If you don’t have transportation, you can schedule a ride when you need to go to an appointment for a covered service. Call Southeastrans at 1-877-892-3986 (TTY: 711), Monday through Friday, 6:00 a.m. to 6:00 p.m. to set up a ride. Trips need to be scheduled at least five business days beforehand. Weekends and holidays do not count toward these days

Behavioral Health Services Administrator (BHSA)

Some behavioral health services, such children’s residential treatment and therapeutic foster care case management, are covered for you through Magellan of Virginia is the behavioral health services administrator (BHSA) for the Department of Medical Assistance Services (DMAS). The Optima Health member services department can help coordinate the services you need, including those that are provided through the BHSA.

Mental Health Services and Trauma Informed Care

Optima Health provides coverage for traditional inpatient and partial psychiatric hospitalization. Mental Health Services include Enhanced Behavioral Health (EBH) Services, and Mental Health Case Management. These services are for members who have experienced potentially traumatic events in the past.

Trauma refers to intense and overwhelming experiences that involve serious loss, threat or harm to a person’s physical and/or emotional well-being. These experiences can happen at any time in someone’s life. They may involve a single traumatic event or may be repeated over many years. People often find a way of coping that may work in the short run, but can cause serious harm in the long run if the trauma is not correctly addressed.

Optima Health’s in-network providers deliver services to members through a trauma-informed care framework and are ready to work with members.

Addiction and Recovery Treatment Services (ARTS)

Optima Health offers many services that help individuals who are living with substance use including alcohol and drug use. Addiction is a medical illness. Many people face addiction, and can benefit from treatment. If you need treatment for addiction, we provide services to help you.

Optima Health covers the following ARTS services:

• inpatient acute detoxification hospitalization
• partial hospitalization
• group home/halfway house
• residential treatment facility services
• substance abuse intensive outpatient treatment
• outpatient (individual, family, and group) substance abuse treatment
• opioid treatment services (includes individual, group counseling; family therapy and medication administration)
• substance abuse peer specialist services.

Medication-assisted treatment is also covered for prescription or non-prescription drug addiction. Peer services are provided by someone who has experienced similar issues and are in recovery. Care coordinator services are also available to members.

Accessing Addiction and Recovery Treatment Services (ARTS)

Talk to your Primary Care Provider (PCP) or call Optima Health’s care coordinator to figure the best option for you and how to get help in addiction and recovery treatment services.

To find an ARTS provider, you can do any of the following:

• look in the Provider and Pharmacy Directory
• visit our website at optimahealth.com
• call your Optima Health Care Coordinator
• call Behavioral Health member services at 1-757-552-7174 for Optima Family Care members, 1-757-552-7580 for Optima Health Community Care members, or call the toll free number at 1-888-946-1168 for both Optima Family Care and Optima Health Community Care members.

If you have any questions or if you are interested in finding out more about ARTS, please do not hesitate to reach out to us. We hope you will take advantage of these services that are a benefit and are available at no cost to you.

Prior Authorizations for Behavioral Health and ARTS

Optima Health requires a prior service authorization for:

• all inpatient behavioral health and substance abuse admissions to hospitals
• partial hospitalization
• residential treatment
• substance abuse group home / halfway house treatment
• intensive outpatient substance abuse services

We also require prior service authorization for the following Mental Health services:

• Mental health care coordination: Services to help you find needed medical, social, educational, and other resources.
• Therapeutic day treatment services for children (TDT): Services for children with severe behavioral problems. It provides 2 hours a day of counseling for children during or after the school day. Workers will help with teaching about medication, build daily living skills, building social skills, individual, group and/or family counseling and care coordination.
• ** NEW EBH Service beginning 7/1/2021 Mental health partial hospitalization program (MH-PHP) This program and is for children and adults and is designed to support and prevent psychiatric hospitalization. It can also be an in-between service for members who are coming from a psychiatric hospital stay and need extra counseling. A team will work with a member 20 hours per week, 5 days per week doing intense therapy.
• ** NEW EBH Service beginning 12/1/2021 Mobile Crisis: Rapid response service that responds to behavioral health crisis. This service is about maintaining safety and refer to behavioral health services and support.
• ** NEW EBH Service beginning 12/1/2021 Community Stabilization: Short-term service designed to help members with crisis response. They will work to set up other mental health services, continue to watch for safety concerns, provide education mental health crisis, and help find a support system for the member.
• ** NEW EBH Service beginning 12/1/2021 23-Hour Crisis Stabilization: This service gives time to decide whether a member needs to go to the hospital for a mental health crisis or if another mental health service may be able to help.
• ** NEW EBH Service beginning 12/1/2021 Residential Crisis Stabilization: A short-term residential program that is one step down from a psychiatric hospitalization. This service aims to help a member get through a mental health crisis and find support in the community.
• ** NEW EBH Service beginning 7/1/2021 Assertive Community Treatment (ACT): This service gives long-term treatment, rehabilitation, and support to members with severe mental illness and provides 24 hour on-call support.
• ** NEW EBH Service beginning 7/1/2021 Mental Health Intensive Outpatient Services (MH-IOP): A service provided when a member is at risk for psychiatric hospitalization. Members age 6­–17 would get 6 hours per week of very intensive therapy. Adults over age 18 would get 9 hours of intensive therapy each week.
• Mental Health Skill-Building Services (MHSS): This service is for members with serious mental illnesses who need help to learn how to improve their life and need less help later. Members learn how to complete daily living skills, understand why medication is important and how to take it, understand health conditions and how to care for them, good nutrition, and physical condition.
• Intensive In-Home Services: This service is for members under age 21 who are at risk of being removed from their home. It is usually short-term and intense. The service is to help the family learn how to get along, provide modeling, and improve relationships within the family.
• Psychosocial Rehabilitation Services: This service is for groups of individuals in the community. Service provides skills for independent living, learning social skills, and how to get along with others. It is two or more hours a day, several days a week.
• Mental Health Peer Support Services: Services are provided by an individual that has lived experience with mental health conditions and/or substance use disorder that is successful in ongoing recovery. Service supports member with resources, and self-help efforts. It can be provided either individually or in groups.
• ** NEW EBH Service beginning 12/1/2021 Multi-Systemic Therapy (MST): This service is provided in the home and community to for children ages 11–17 who have very severe behavioral problems. Service focuses on overcoming barriers to behavior change, safety planning, and crisis intervention. Referral is needed from juvenile justice, behavioral health, school, or child welfare system.
• ** NEW EBH service beginning 12/1/2021 Functional Family Therapy (FFT): This is a home-based service for children ages 11-18 provides help for behavioral or emotional problems including co-occurring substance use disorders. It focuses on the whole family to understand risk and protective factors. Referral is needed from juvenile justice, behavioral health, school, or child welfare system.

To find out more about how to request approval for these treatments or services, contact Behavioral Health member services at 1-757-552-7174 for Optima Family Care members, 1-757-552-7580 for Optima Health Community Care members, or call the toll free number at 1-888-946-1168 for both Optima Family Care and Optima Health Community Care members.

Any person or child admitted to a Therapeutic Group Home (TGH) will not be excluded from the Medallion 4.0 or CCC Plus Program, however, the TGH per diem service is “carved out” of the Medallion 4.0 and CCC Plus contracts and will be administered through Magellan of Virginia. Any professional medical services rendered to individuals in the TGH will be administered by Optima Health.