Implementing Medicaid Behavioral Health Reform in New York - PowerPoint PPT Presentation

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Implementing Medicaid Behavioral Health Reform in New York

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Implementing Medicaid Behavioral Health Reform in New York
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Implementing Medicaid Behavioral Health Reform in New York

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  1. Redesign Medicaid in New York State Implementing Medicaid Behavioral Health Reform in New York NYSRA-NYSACRA Community Integration Leadership Institute: Advancing Outcomes June 3, 2014

  2. Agenda • Overview of BH Transition to Managed Care • BHO Phase 2 Status • Behavioral Health Managed Care Transition Timeline • RFQ Standards • Next Steps 2

  3. BH Transition to Managed Care 3

  4. Medicaid Redesign Team: Objectives • Fundamental restructuring of the Medicaid program to achieve: • Measurable improvement in health outcomes • Sustainable cost control • More efficient administrative structure • Support better integration of care 4

  5. Medicaid Redesign Team BH Recommendations • Behavioral Health will be managed by: • Qualified health Plans meeting rigorous standards (perhaps in partnership with a BHO) • All Plans MUST qualify to manage currently carved out behavioral health services and populations • Plans can meet State standards internally or contract with a BHO to meet State standards • Health and Recovery Plans (HARPs) for individuals with significant behavioral health needs • Plans may choose to apply to be a HARP with expanded benefits 5

  6. Principles of BH Benefit Design • Person-Centered Care management • Integration of physical and behavioral health services • Recovery oriented services • Patient/Consumer Choice • Ensure adequate and comprehensive networks • Tie payment to outcomes • Track physical and behavioral health spending separately • Reinvest savings to improve services for BH populations • Address the unique needs of children, families & older adults 6

  7. Qualified Plan vs. HARP Qualified Managed Care Plan Health and Recovery Plan • Medicaid Eligible • Benefit includes Medicaid State Plan covered services • Organized as Benefit within MCO • Management coordinated with physical health benefit management • Performance metrics specific to BH • BH medical loss ratio • Specialized integrated product line for people with significant behavioral health needs • Eligible based on utilization or functional impairment • Enhanced benefit package - All current PLUS access to 1915i-like services • Specialized medical and social necessity/ utilization review for expanded recovery-oriented benefits • Benefit management built around higher need HARP patients • Enhanced care coordination - All in Health Homes • Performance metrics specific to higher need population and 1915i • Integrated medical loss ratio 7

  8. Behavioral Health Benefit Package • Behavioral Health State Plan Services –Adults • Inpatient - SUD and MH • Clinic – SUD and MH • PROS • IPRT • ACT • CDT • Partial Hospitalization • CPEP • Opioid treatment • Outpatient chemical dependence rehabilitation • Rehabilitation supports for Community Residences (Not in the benefit package in year 1) 8

  9. Menu of 1915i-like Home and Community Based Services - HARPs • Rehabilitation • Psychosocial Rehabilitation • Community Psychiatric Support and Treatment (CPST) • Habilitation • Crisis Intervention • Short-Term Crisis Respite • Intensive Crisis Intervention • Mobile Crisis Intervention • Educational Support Services • Support Services • Family Support and Training • Training and Counseling for Unpaid Caregivers • Non- Medical Transportation • Individual Employment Support Services • Prevocational • Transitional Employment Support • Intensive Supported Employment • On-going Supported Employment • Peer Supports • Self Directed Services 9

  10. BHO Phase 2 Status 10

  11. BHO Phase 2 Status • Revised RFQ based on RFI comments • RFQ distributed (with draft NYC HARP rates) on March 21, 2014 • OMH: • DOH: • RFQ Applicant’s Conference held on May 2, 2014 in NYC • NYC Applications due June 6, 2014 • Rest of State - approximately six months later 11

  12. 12

  13. RFQ Standards 13

  14. Cross System Collaboration Quality Management Reporting and Performance Management Claims Processing Information Systems and Website Capabilities Financial Management Performance Incentives Implementation planning Organizational Capacity Experience Requirements Contract Personnel Member Services Network Service Network Monitoring Network Training Utilization Management Clinical Management RFQ Performance Standards 14

  15. Contract Personnel • HARPs must have full time dedicated BH Medical and Clinical Director • These positions may be shared if the HARP has fewer than 4,000 State identified HARP eligibles • Subject to certain restrictions, Plans may share positions and functions between Mainstream MCOs and HARPs • Plans must demonstrate to NYS that they or their managerial staff meet the experience requirements established in the RFQ • Plans must demonstrate that they have an adequate number of managerial and operational staff to meet the needs of their members. 15

  16. Member Services • Requires Service Centers with several capabilities including: • Provider relations and contracting • UM • BH care management • 24/7 day capacity to provide information and referral on BH benefits • 24/7 day capacity to respond to crisis calls 16

  17. Utilization Management • Plans must use medical necessity criteria to determine appropriateness of ongoing and new services • Plans prior authorization and concurrent review protocols must comport with NYS Medicaid medical necessity standards • These protocols must be reviewed and approved by OASAS and OMH in consultation with DOH • Plans will rely on the LOCADTR tool for review of level of care for SUD programs as appropriate • HARP UM requirements must ensure person centered plan of care meets individual needs 17

  18. Clinical Management • The RFQ establishes clinical requirements related to: • The management of care for people with complex, high-cost, co occurring BH and medical conditions • Promotion of evidence-based practices • Pharmacy management program for  BH drugs • Integration of behavioral health management in primary care settings • Additional HARP requirements include oversight and monitoring of: • Health Home services and 1915(i) assessments • Access to 1915(i)-like services • Compliance with conflict free case management rules (federal requirement) • Compliance with HCBS assurances and sub-assurances (federal requirement) 18

  19. Network Service Requirements • Plan’s network service area consists of the counties described in the Plan’s current Medicaid contract • There must be a sufficient number of providers in the network to assure accessibility to benefit package • Transitional requirements include: • Contracts with OMH or OASAS licensed or certified providers serving 5 or more members for a minimum of 24 months • Pay FFS government rates to OMH or OASAS licensed or certified providers for ambulatory services for 24 months • State will review proposed Plan/provider alternative payment arrangements requirements on a case by case basis 19

  20. Network Service Requirements • Plans must contract with: • Opioid Treatment programs to ensure regional access and patient choice where possible • Health Homes • Plans must allow members to have a choice of at least 2 providers of each BH specialty service • Must provide sufficient capacity for their populations • Contract with crisis service providers for 24/7 coverage • Plans contracting with clinics with state integrated licenses must contract for full range of services available • HARP must have an adequate network of Home and Community Based Services

  21. Network Service Requirements: State Operated • Plans must contract for State operated BH ambulatory services • Treated as “Essential Community Providers” • After 2 years, rates will need to be negotiated with Plans. • OMH and DOH will work with the MCOs to make the plans accountable financially and programmatically for • Continuing admissions to the State facilities • Transfers to the State facilities 21

  22. Network Training • Plans will develop and implement a comprehensive BH provider training and support program • Topics include: • Billing, coding and documentation • Data interface • UM requirements • Evidence-based practices • HARPs train providers on HCBS requirements • Training coordinated through Regional Planning Consortiums (RPCs) when possible • RPCs are comprised of each LGU in a region, representatives of mental health and substance abuse service providers, child welfare system, peers, families, health home leads, and Medicaid MCOs • RPCs work closely with State agencies to guide behavioral health policy in the region, problem solve regional service delivery challenges, and recommend provider training topics • RPCs to be created 22

  23. Claims Administration • The RFQ language allows Plans flexibility to pay for services using telemedicine consistent with Federal standards • The RFQ requires that Plans accept web-based claims • Plans must track and pay Health Homes to administer care coordination 23

  24. Year One Performance Measures • Year One Performance Measures • Existing QARR and Health Home measures for physical and behavioral health for HARP and MCO product lines • BHO Phase 1 measures will continue to be run administratively • New measures being proposed for HARPs based on data collected from 1915(i) eligibility assessments • Member Satisfaction – all are existing QARR measures • Based on CAHPS survey • A recovery focused survey for HARP members is also being developed.  Measures derived from this survey may be created in the future 24

  25. Financial Management • HARP rate does not include 1915(i) home and community based services • In the first year, HCBS paid on a non-risk basis • Plans will act as an Administrative Services Organization (ASO) • NYS will identify and designate 1915(i) providers • NYS will establish initial 1915(i) payment rates 25

  26. Financial Management • State is modifying current psychiatric inpatient stop loss policy for Mainstream Plans and HARPs • Change to episodes of care - replaces stop loss based on cumulative days per person per year • Increases Plan financial responsibility for days of care over three years • Financial impact of psychiatric inpatient stop-loss proposal: • If no change, NYS would reimburse the MCOs about $240 million in psychiatric stop loss • With the change, by year 3 and after, Plan premiums increase by $210 million while the stop-loss pool is reduced to $30 million

  27. Performance Incentives (under consideration) • Mainstream MCOs: • Bifurcate the mainstream QI award • Award a percentage of the existing performance pool (more than $200M) separately based on behavioral health measures • HARPs: • Year one: no withhold or quality incentive • Year two: up to a 1% withhold to pay a quality incentive • Year three: up to 1.5% withhold to pay a quality incentive • Year four and ongoing: up to 2.0% withhold to pay a quality incentive 27

  28. Next Steps 28

  29. Next Steps • Ongoing Plan Engagement • Plan/Health Home collaboration: • Identify care management roles and responsibilities beyond the existing Health Home/Plan agreement • Determine the care management model for HARP members and HARP eligibles that are not enrolled in Health Homes • Building Health Home capacity for HARP enrollees • Work with Plans and Health Home to collect and analyze Health Home performance • Risk Mitigation Mechanism • Work with Plans to develop a “Balanced Risk Corridor” and "Effective MLR of 90%" • Finalize performance incentive structure 29

  30. Next Steps • 1915i program development • Develop guidance for 1915i services • Designating 1915i qualified providers • Work with CMS to streamline assurances/sub-assurances • Finalize Year 2 performance measures • NYS will develop a Regulatory Reform Workgroup • Provide ongoing technical assistance for Plans and providers • Implement Start-Up Activities (with funding in 2014-15 Executive Budget) • Facilitate creation of Regional Planning Consortiums (RPCs) 30

  31. OMH Next Steps • Provide Technical Assistance • Data Analysis • Regulatory Reform • Housing Supports • Integration of State Operations • Building OMH (Central and Field Office) capacity for • RPC coordination • Plan/ Provider liaison functions • Plan Oversight