Report from DSHS

1. Report from DSHS Mimi Martinez McKay Chief of Staff/Legislative Liaison DSHS/MHSA TIPSS Conference

2. DSHS Report • FQHC’s in Texas/Health Care Reform • Drug Demand Reduction Advisory Committee (DDRAC) • 2009 recommendations • UPPL • Workforce • Substance Abuse Medicaid Benefit • Current Status

3. Federally Qualified Health Centers Opportunities for Behavioral Health Integration

4. FQHC Partnerships –Key Things to Know • What is a FQHC? • Scope of service • Cost-based reimbursement • BH Expansion Grants for FQHCs • Provisions in healthcare reform

5. What are Federally Qualified Health Centers? • A federally qualified health center (FQHC) is a type of provider defined by the Medicare and Medicaid statutes. FQHCs include all organizations receiving grants under Section 330 of the Public Health Service Act, certain tribal organizations, and FQHC Look-alikes. • A FQHC Look-Alike is an organization that meets all of the eligibility requirements of an organization that receives a PHS Section 330 grant, but does not receive grant funding.

6. Scope of Service • Provides medical, mental health and dental care to all regardless on their ability to pay – uninsured or underinsured • Provides enabling services such as pharmacy, transportation, prenatal and family care services, case management and other basic needs, referrals to other agencies • Provides services through all the life cycles-prenatal, pediatric, adult and geriatrics.

7. Cost-Based Reimbursement • Per provider fee for each encounter regardless of amount of time • Determined based on costs, prospective payment • Potential for increased revenue for psychiatric visits • Federal Tort Claims Act liability coverage • Increased payment for BH staff under this model too

8. BH Expansion Grants • Funding available, often each year, to expand BH services in FQHC settings • Most recent application February, 2009 • All New Starts must have behavioral health services • Direct Hires • Contract with Community Mental Health Centers (CMHCs)

9. FQHC Related Provisions in Healthcare Reform Legislation Prevention and Wellness Programs: Based on integration, which includes substance abuse services: • Establishes a Prevention and Public Health Fund and appropriates $7 billion in funding for fiscal years 2010 through 2015 and $2 billion for each fiscal year after 2015 for prevention, wellness, and public health activities, including prevention research and health screenings, the Education and Outreach Campaign for preventive benefits, and immunization programs. • Provides grants for up to five years to small employers that establish wellness programs.

10. FQHC Related Provisions in Healthcare Reform Legislation • Establishes a demonstration program for health centers to receive funding for drafting individualized patient wellness plans. • Directs the President to establish the “National Prevention, Health Promotion and Public Health Council” composed of the heads of Federal departments and agencies (including HHS, DHS, Agriculture, Transportation, FTC, FCC, etc.), dedicated to promoting “healthy policies” at the federal level, as proposed in the HELP Committee bill. • Formally establishes and charges the Community Preventive Services Task Force to review effectiveness of clinical and community-based preventive services and make recommendations.

11. FQHCs in Texas • Texas currently has 70 Federally Qualified Health Centers. For more information on FQHCs access the directory at: http://www.dshs.state.tx.us/chpr/FQHCmain.shtm • The Texas Association of Community Health Centers can be found at: http://www.tachc.org/

13. Financial Costs

14. Latest BH funding to FQHC’s

15. Resources The Partners in Health Primary Care/County Mental Health Collaboration Toolkit offers an overview on the types of affiliation agreements that FQHCs can pursue for behavioral health care services, and can be found at: http://www.thenationalcouncil.org/cs/tools_tips

16. DDRAC Drug Demand Reduction Advisory Committee

17. 2009 DDRAC Recommendations • Remove the exclusion clause for medical expenses from the Uniform Individual Accident and Sickness Policy Provision Law (UPPL). • Expand the Texas Prescription Program to allow the proactive prevention of prescription drug abuse. • Mandate comprehensive alcohol and other drug reduction strategies, targeting college students, that includes enforcement of campus policy violations. • Pass a statewide public smoking ban eliminating smoking in all workplaces and public places statewide. • Support the recruitment and retention of quality service professionals in the field of substance abuse prevention and treatment by increasing funds to support wage.

18. Uniform Individual Accident and Sickness Policy Provision Law (UPPL) Recommendation and Rational for Repeal

19. Uniform Individual Accident and Sickness Policy Provision Law (UPPL) UPPL allows insurance companies to exclude medical coverage for injuries if patients are under the influence of alcohol or unprescribed drugs, thus creating a major barrier to screening and intervention. DDRAC Recommendation: Remove the exclusion clause for medical expenses from the UPPL.

20. UPPL Rationale: • UPPL allows insurance companies to exclude medical coverage for injuries if patients are under the influence of alcohol or unprescribed drugs. • The Texas UPPL exclusion has an adverse financial impact on patients, hospitals, and healthcare providers. • Financial concerns cause healthcare providers to avoid screening for alcohol and drug abuse, jeopardizing trauma center certification and hindering the identification and treatment of substance abusers. • Failure to conduct these screenings interferes with the prosecution of injured drunk drivers.

21. Efforts to Repeal UPPL Texas update: • HB 634 (Eiland), prohibiting the exclusion of coverage described above, was filed on 1/17/07 and left pending by House Committee on Insurance on 4/17/07. • Screening and brief intervention for emergency room patients through the Texas InSight Project in the Harris County Hospital District reduced costs to the Hospital District by more than $4 million. Other information: • In December 2009, Ohio became the most recent state to repeal the UPPL by a vote of 32-0 in their Senate and 93-1 in their House of Representatives. • California addressed concerns that the repeal would constitute an insurance mandate by clarifying the statutory nature of the UPPL. By only removing the statutory permission, CA insurance companies must now negotiate the exclusion upfront if they choose to do so. • As of 2010, eight states do not have health/sickness exclusion laws, and 13 states prohibit the denial of benefits

22. 2010 Workforce Proposed Recommendations ASAP/TAAP/DDRAC ASAP/TAAP/DDRAC

23. Workforce Recommendations • Allow persons with a bachelor’s or more advanced degree in a “non related” field to enter the field as a Counselor Intern (CI) upon completing 270 classroom hours of accredited chemical dependency education. Rational: Studies indicate that the chemical dependency counseling field is highly representative of persons in secondary careers. A bachelor’s or higher degree demonstrates educational accomplishment and the required 270 classroom hours of education provide the necessary subject matter expertise.

24. Workforce Recommendations • Clarify current interpretation and/or change the statute to eliminate the prohibition that individuals with criminal records cannot begin their CI status until they have met required sanctions. Rational: It is prohibitive for many people to wait 5-7 years to begin their CI status.   By the time they qualify, most have found other employment and their passion for working in the field is abated. 

25. Workforce Recommendations • Establish reciprocity guides for each state and all branches of the military. Rational: Legislation to update Texas licensure law to reflect current IC&RC standards was introduced during the 81st legislative session but was not passed in the final days of the session • Change current 448.607 (d) to allow former clients to work at a facility one year after documented discharge from active services. Rational: Reducing the waiting time to one year both provides the necessary distance from a treatment experience as well as one year in recovery to appropriately be employed in non-direct care positions with limited client contact.

26. Workforce Recommendations • To support counselors and aid in career retention, require enrollment in a peer assistance program rather than the current stipulation to show “documented access to” these programs Rational: Enrollment in peer assistance programs is a requirement for most professions and will lend additional credibility and professionalism to the field.

27. Workforce Recommendations • Provide displaced workers in Texas with information and awareness about the chemical dependency counseling field Rational: Requesting the Texas Workforce Commission (TWC) to designate LCDCs as an in demand occupation will allow access to federal dollars through programs such as the Workforce Investment Act (WIA) be used for re-training displaced workers as chemical dependency counselors.

28. Workforce Recommendations • Encourage state leadership to assist in working with the Texas State Board of Social Worker Examiners to allow LMSW’s to continue as a Qualified Credentialed Counselor (QCC) in chemical dependency treatment facility without the supervision of an LCSW. Rational: Many facilities employ LMSW’s as QCCs and are faced with the decision to let them go because they cannot afford to keep them on staff without a QCC designation or afford to find and hire a LCSW. • Promote the chemical dependency counseling career through all appropriate avenues and methods of dissemination

29. SUD Medicaid Benefit • Outpatient Services (9/1/2010) • Clinical assessment. • Ambulatory Detoxification. • Outpatient individual and group chemical dependency counseling. • Medication assisted treatment. • Residential Services (1/1/2011) • Residential detoxification. • Residential treatment.

30. How will clients be able to access the new SUD treatment benefits? • A Medicaid client can self-refer or be referred to receive an assessment. No referral from a primary care physician is needed. • An assessment must be made before services can begin. No prior authorization is needed for an assessment.

31. Who is the primary payer or payer of last resort? • Clients eligible for Substance Abuse block grant services: • Medicaid pays first if the benefit is covered by both the block grant and Medicaid • Medicaid clients with private insurance: • Private insurance pays first. • Medicaid pays for Medicaid-covered benefits not covered by the client’s private insurance.

32. How are providers reimbursed? • Generally, SUD treatment providers will be reimbursed by: • STAR, STAR+PLUS - through the Medicaid managed care health plans. • STAR+PLUS clients receiving Supplemental Security Income (SSI)-through the Medicaid managed care health plans. • PCCM and FFS - through TMHP. • NorthSTAR – through the BHO, Value Options.

33. How long does it take? • The state requires that health plans pay providers within 30 days of receiving a “clean” claim, or a claim that has all required elements. The HMO is contractually obligated to meet this requirement. Likewise, TMHP has 30 days to process a clean claim for PCCM and FFS.

34. For more information . . . • About the Texas SUD treatment benefits for adults in Medicaid, contact HHSC SUDTreatmentBenefit@hhsc.state.tx.us • By phone: 512/491.1162 • HHSC plans to offer training to providers via an interactive desk-top webinar and in select locations around the state later this summer.

35. Contact information mimi.mckay@dshs.state.tx.us 512/206.5804