The Medicaid program was established by Title XIX of the Social Security Act in 1965. It was created as a joint federal and state program that pays for medically necessary services for certain individuals and families that meet specific criteria such as income eligibility. In Pennsylvania, the Medicaid program is referred to as Medical Assistance. Under the guidelines established by the federal government, each state administers its own programs, establishes its own criteria for eligibility and determines the type of services to be delivered. A state can pay a Medicaid vendor directly under a “fee-for-service arrangement,” or they may use third parties such as a health maintenance organization (HMO) or managed care organization (MCO) to handle payments for Medicaid-funded services.
In 1996, Pennsylvania introduced HealthChoices. This model created a mandatory managed care program for certain Medicaid recipients. The previous “fee-for-service” model, however, remained in existence for those recipients that did not meet the HealthChoices criteria.
Two main components of HealthChoices were created at that time. The first component created physical health managed care organizations, or PHMCOs. The second component created behavioral health managed care organizations, or BHMCOs. More recently a third program called Community HealthChoices was created. This program provides management of long-term care benefits for people who meet the eligibility requirements. The goal of the state is to ensure that, although there are separate primary components to the model, an integrated system of care can be provided to all the eligible recipients.
The Department of Human Services, or DHS, created the HealthChoices program with the establishment of different zones within Pennsylvania. The original twenty-three member counties of the Behavioral Health Alliance of Rural Pennsylvania, otherwise known as BHARP, comprised the initial North Central State Option Zone for behavioral health which was started on January 1, 2007.
Currently, services traditionally funded by county base and Act 152 funds are both still authorized and reimbursed through the various county offices that previously funded those services. This includes the base service units and the single county authorities. Eligibility determination is still one of the primary functions of the County Assistance Office. Under this model, the managed care organization can’t determine or change an individual’s eligibility status. Additionally, not all Medicaid recipients meet the eligibility criteria for HealthChoices. That means services provided to those recipients are still reimbursed on a “fee-for-service” basis.
When the DHS, which was formerly known as the Department of Public Welfare, designed the Medicaid Managed Care Program, it was decided that the Office of Mental Health and Substance Abuse Services (OMHSAS) would oversee the behavioral health component of HealthChoices. OMHSAS decided that Pennsylvania county governments would be offered “right of first opportunity” to enter into fixed amount, or capitated, contracts with the Commonwealth for the administration of the HealthChoices behavioral health program. This program is the mandatory managed care program that provides Medicaid recipients with services to treat mental health and/or substance abuse diagnoses/disorders.
Forty-three of the sixty-seven counties within Pennsylvania originally signed agreements for the “right of first opportunity.” They then sub-contracted with a private sector behavioral health managed care organization to manage their portion of the HealthChoices behavioral health program. At that same time, twenty-four counties within the state elected not to enter into a fixed amount agreement. That means that currently, DHS/OMHSAS holds agreements with two managed care organizations to directly manage the HealthChoices behavioral health program in those counties. Currently, the twenty-four counties known as BHARP, comprise one of the two state-held contracts.
In December of 2006, BHARP was established at the request of OMHSAS. The purpose of the alliance was to provide a way for the county mental health/intellectual disabilities, also known as MH/ID administrators, human service directors, and single county authorities, or SCAs, in the original twenty-three BHARP counties to have input into the implementation of the North Central State Option HealthChoices contract. In total, there are fourteen county entities that provide MH/ID representation and thirteen county/private entities that provide drug and alcohol representation. BHARP currently represents many of the rural counties in Pennsylvania. Covered lives within the program total over 198,000 for the HealthChoices program.
Since its inception, BHARP has been unique in both its structure and its role in HealthChoices. The BHARP board has, from the beginning, acted as a full partner in the implementation and ongoing management of the North Central contract, despite the fact that was a state-held contract. Just as important is the level of collaboration among the BHARP members that represent both county MH/ID and drug and alcohol administrators. While other HealthChoices programs may have drug and alcohol participation, it’s unusual to see the level of collaboration and participation that is present in the BHARP model.
The current contract overseen by BHARP covers twenty-four rural counties which represent a large geographic area in Pennsylvania. Within BHARP, there are counties that have fully integrated human service models, privatized county models, county-held drug and alcohol services, and private commission drug and alcohol services. BHARP counties vary in size and the number of HealthChoices eligible members varies from as few as 895 people in a single county to as many as 30,508 people. Despite these variations, BHARP has been successful in creating a structure for the program. BHARP has also been able to assure that all member counties have had equal access to funding through reinvestment, equal say in priorities for the medical dollars, and equal opportunity for the implementation of supplemental services designed to enhance the service system.
In its first year of operation, BHARP established workgroups to focus on services for priority populations which were identified by BHARP members. The workgroups also planned to focus on the creation of recovery-oriented services in all of the BHARP counties. These workgroups had participation from BHARP members, OMHSAS, the behavioral health managed care organization, and other stakeholders. From those workgroups, service descriptions for new programs were developed and implemented.
Specialty programs serving individuals with MH/ID diagnosis were developed by BHARP’s Dual Diagnosis workgroup. Those programs are still serving individuals within the North Central region, as well as statewide. To date, the BHARP Recovery workgroup has sponsored two recovery conferences with over 200 attendees at each conference. From the recovery conferences, BHARP has been able to fund small county projects aimed at increasing collaboration with physical health and clergy in local communities.
In addition to the accomplishments of the workgroups, BHARP quickly established a reputation for advocating for the rural counties and their members. BHARP staff participate in statewide workgroups sponsored by the County Commissioners Association of PA (CCAP) affiliates and OMHSAS. BHARP’s role in those groups is to assure that any recommendations and policies developed will take into consideration the needs of rural counties. This participation allows BHARP to establish a strong reputation for advocacy for the rural and underserved counties.
BHARP’s participation in these workgroups led to the first state-approved tele-mental health program, which was developed in Sullivan County. Other BHARP accomplishments include a rental assistance program for nine counties that was initially administered by the Clarion County Housing Authority. This program has been recognized on both the federal and state level for its collaboration among county MH/ID administrators, single county authorities, housing authority administrators and the Pennsylvania Housing and Finance Agency.
In conjunction with Columbia, Montour, Snyder and Union (CMSU) counties, BHARP helped to secure a SAMHSA (Substance Abuse and Mental Health Services Administration) System of Care (SOC) Grant for $4,000,000. The grant was implemented in eight Tier One counties. To be considered as part of the Tier One group, a county had to commit to participating in the grant activities at the highest level. The remaining fifteen counties, however, would also benefit from the work being done, as well as benefit from the funding itself.
Over the past several years, SAMHSA has called on the BHARP SOC team to speak during national conference calls, as well as events with other grantees. The goal was to share our de-centralized, locally-controlled approach to achieving the goals of the grant in a rural setting. These goals included developing a family and youth-driven system of care, developing local county leadership teams, and creating trauma-informed system transformation.
In conjunction with BHARP’s approach to engaging member counties based on their strengths and needs, the System of Care project supported Tier One counties through funding allocations directly from the grant. The project ream also chose the training vendor for trauma programs based on the counties’ recommendation. Lakeside Global Institute, the training vendor, has brought enormous resources to the BHARP member counties through training, access to world leaders in trauma work, and sustainability planning through a train-the-trainer model. Another successful outgrowth of the System of Care grant is the Open Table Faith Government partnership. This program brings together government entities and faith communities to support individuals using the social services system and lift them out of poverty.
Over the years, as BHARP continued its work around assuring there was a cost-effective, quality-driven system of care in the rural counties, it became apparent that BHARP needed to function as an independent entity. Through the work of the board, BHARP began to explore options for shifting from an unincorporated alliance to a nonprofit corporation. BHARP worked with legal counsel to choose a structure that would best meet their needs and assure BHARP could continue to pursue grant opportunities at the state and federal level. In January of 2018, BHARP was granted status as a Pennsylvania nonprofit corporation. Since that time, the BHARP board has supported and directed exploration of additional grant opportunities. This includes a SAMSHA TREE grant designed to support families with youth and young adults in recovery from substance use disorders.
On July 1, 2021, BHARP became the primary contract holder for the North Central HealthChoices program. This decision was made in part because of BHARP’s advancements in services, a history of successful support for large, regional projects such as the System of Care grant, and the organization’s responsiveness to the unique needs of social service systems in rural counties. Additionally, on January 1, 2022, Greene County joined BHARP and became the twenty-fourth member of the alliance.