Mental Health and AODA Services

Mental Health, alchohol and drug abuse services : Your Healthy Family : Legal Action of Wisconsin

Mental Health, Alcohol and
Drug Abuse (AODA) Services
Knowing how to access mental health, alcohol and drug abuse (AODA) treatment is important. Some common questions are:
Who do I call if I need mental health services or alcohol and drug treatment?
Your primary care provider does not manage mental health and AODA services. You need to get special permission from the mental health gatekeeper assigned to your HMO.
What is a mental health gatekeeper?
Each HMO contracts with a company chosen to coordinate mental health or AODA treatment for its enrollees. This company is known as the “gatekeeper.” The gatekeeper will do an assessment of your needs and then refer you to a psychiatrist, psychologist or counselor who will give you the services you need.
You do not need to first contact your primary care provider for mental health/AODA services. You can call the gatekeeper directly. See HMO ADOVOCATES
What if I have problems getting services?
If you have problems getting mental health/AODA services or you are not satisfied with the quality of these services:

You should discuss your problem with the mental health gatekeeper.

If you don’t feel that your problem has been resolved, contact your HMO Advocate and explain what has happened.

After talking with your HMO Advocate, if you still feel that your problem hasn’t been resolved you can file a grievance with your HMO or request a fair hearing from the Division of Hearings and Appeals. See FILING A GRIEVANCE or REQUESTING A FAIR HEARING

Note: If your mental health or AODA services are being stopped or reduced, file a fair hearing request within 10 days of the notice you receive telling you your services are going to be stopped or reduced.
Only if you request a fair hearing will your services be continued while your problem is being resolved. Filing a grievance will not let you keep getting your services while a decision is being made on your complaint.

Your mental health provider must provide all medically necessary services including inpatient and outpatient care.

For a Medicaid recipient there cannot be a limit on the amount of medically necessary services.

If the gatekeeper unreasonably limits, reduces or terminates your services, you can file a grievance or request a fair hearing.

Contact the Managed Care Ombuds Program at 800-760-0001 or the Health Advocacy Project at Legal Action of Wisconsin at 414-278-7722 or Community Advocates at 414-449-4777 if you have trouble getting mental health/AODA services.