December 8, 2015

Conference of Local Mental Hygiene DirectorsMonthly CallNYS OMH Update

Children’s Service System Transformation in Brief

2

Medicaid Redesign Team’s Vision, Goals and Principles for Transforming the Delivery of Heath Care for Children

Keep children on their developmental trajectoryFocus on recovery and building resilienceIdentify needs early and interveneMaintain child at home with support and servicesMaintain the child in the community in least restrictive settingsPrevent escalation and longer term need for higher end servicesMaintain accountability for outcomes and qualityMaintain and expand access to services for children without Medicaid

as a “Household of One”

December 8, 2015

Get children back on their developmental trajectory: • Identify needs early• Maintain the child at home with support and services• Maintain the child in the community, in least restrictive settings• Prevent longer term need for higher end services

The GOAL is to…

December 8, 2015 3

Focus on recovery and

building resilience!

Children’s Timeline Overview

December 8, 2015 4

Children’s Transition Timeline

• Children will begin to enroll in Health Homes Designated to Serve Children on September 1, 2016.

• OMH TCM providers and legacy clients will transition on September 1st as well. • The transition of care coordination services of the five 1915c children’s Waivers (OMH SED,

DOH Care at Home I/II, OCFS Bridges to Health) to Health Home will not occur until 2017.

• The newly proposed health and behavioral health Medicaid State Plan services will be implemented as soon as possible pending approval from CMS in 2016. The services will transition to Managed Care in 2017.

Geographic Phase In• January 1, 2017 – NYC and Long Island Children's Transition to Managed Care • July 1, 2017 – Rest of State Children's Transition to Managed Care

December 8, 2015 5

Children’s Transition Timelines - continued• In 2017, currently carved out Medicaid behavioral health services and children in foster care will

be moved to Managed Care

• The existing Home and Community Based Services (HCBS) that are in the five 1915c children’s Waivers (OMH SED, DOH CAH I/II, OCFS B2H) will be aligned to one array of HCBS benefits, pending CMS approval, and will be moved to Managed Care. As a result of this transition, the 1915c Waivers will be discontinued as separate programs once the transition is complete.

• Children enrolled in the 1915c Waivers on January 1 and July 1, 2017, will transition to Managed Care and continue receiving HCBS benefits as per their service plan for 90 days, before service plan review by the Plans

• In 2017, newly identified children meeting Level of Care criteria may begin to receive HCBS benefits.

• In 2018, children meeting Level of Need criteria will begin to receive HCBS benefits (January for children with Medicaid; July for children who meet “family of one” Medicaid)

December 8, 2015 6

December 8, 2015 7

Enrollment of Children in Health Homes• Children who have no access to care coordination can access it

• There will be one single model for care coordination of children, integrating physical and behavioral health

• OMH TCM providers and the children they serve will transition to Health Home in 2016

• HCBS Waiver care managers and the children they serve will transition to Health Home when the managed care transition occurs in 2017

• Update on the Implementation of Health Homes for Children – Webinar coming on December 16, 10:00-12:00

OASAS Service Changes

• Clinic to Rehabilitation Designation Change - services where kids and families are

• LOCADTR-3 - adolescent version

• Residential Redesign - Medicaid reimbursement 

• Access to all SPA services

• Health Home access for eligible youth

• HCBS access for eligible youth

• Family/Peer supports

December 8, 2015 8

Looking a Little More Closely -Children’s State Plan Amendment

December 8, 2015 9

December 8, 2015 10

Implementation of new Medicaid SPA Services• New York will have more Medicaid service options available to intervene earlier

when a child and family experiences behavioral health and other challenges

• Available to all Medicaid eligible children who meet medical necessity criteria

• New York will be able to reimburse Evidence Based Practices through Medicaid

• Unlicensed practitioners, as well as licensed practitioners, will be able to deliver new services

• Family and youth peers will be able to provide services under Medicaid authority

December 8, 2015 11

Current Action Steps - prior to Submission to CMS• Rate development

• Finalization of Evidence Based Practice Designation process

• Regulation development

• Finalization of Provider Designation Process

• Finalizing SPA Provider Manual

• Crisis Intervention

• Community Psychiatric Supports and Treatment (CPST)

• Other Licensed Practitioner

• Psychosocial Rehabilitation Services

• Family Peer Support Services

• Youth Peer Advocacy and Training

Proposed New Medicaid State Plan Services

December 8, 2015 12

Chart provided to call participants detailing unique features of each service along with case examples of how the services might address individual needs.

SPA Services Distinction

December 8, 2015 13

• 24/7 availability with one hour response time

• Mobile team-based service in the community where crisis is occurring

• For a child and his/her family/caregiver who is experiencing a psychiatric or substance use crisis

• Intended to interrupt and/or ameliorate a crisis experience including an assessment, immediate crisis resolution and de-escalation, development of a safety plan, and referral/follow up to additional supports

Crisis Intervention

December 8, 2015 14

• Services provided by a certified and trained peer with lived experience

• Family Peer Support Services - array of formal and informal services and supports provided to families caring for/raising a child who is experiencing social, emotional, developmental, substance use and/or behavioral challenges

• Youth Peer Advocacy and Training Services – services that provide the training and support necessary to ensure engagement and active participation of the youth in the treatment planning process and with the ongoing skill development learned throughout the treatment process

Family Peer Support and Youth Peer Advocacy and Training

December 8, 2015 15

• Goal-directed supports and solution-focused interventions intended to achieve identified goals or objectives as set forth in the child’s plan of care.

• Face to face intervention, which may include collateral contact

• Delivery in the community by unlicensed practitioner

• Includes the delivery of authorized Evidence Based Practices

Community Psychiatric Supports and Treatment (CPST)

December 8, 2015 16

• Implement interventions outlined on a treatment plan to compensate for or eliminate functional deficits and interpersonal and/or environmental barriers associated with a child/youth’s behavioral health needs

• Intent is to restore the fullest possible integration of the individual as an active and productive member of his or her family, community and/or culture with the least amount of ongoing professional intervention

• Delivered by unlicensed practitioner, under clinical supervision

Psychosocial Rehabilitation Services

December 8, 2015 17

• A licensed behavioral health practitioner, licensed in the State of New York to prescribe, diagnose and/or treat individuals with mental illness or substance abuse operating within the scope of practice defined in State law and in any setting permissible under State practice law.

• Will include individuals licensed as: Registered Professional Nurse, Licensed Nurse Practitioner, Licensed Psychologist, Licensed Social worker (LMSW, LCSW), and Licensed Mental Health Counselor

Other Licensed Practitioner

December 8, 2015 18

• Service Definitions

• Allowable Activities

• Modality (e.g., face-to-face individual or group)

• Setting

• Admission/Discharge Criteria (i.e., medical necessity)

• Limitations/Exclusions

• Agency/Staff/Supervisor Qualifications

• Training

SPA Provider Manual

December 8, 2015 19

December 8, 2015 20

What is the 1115 and Why Amend?

• Approved in 1997

• Federal authority to operate a Managed Care Delivery System

• Amendments required with transition of new populations or services and/or development of new demonstrations or services

• Children’s amendment to be submitted to CMS in early 2016

New York’s 1115 Partnership Plan

December 8, 2016 21

December 8, 2015 22

Many changes result from the 1115• Existing behavioral health services will transition to Medicaid managed care, including

newest six children’s services

• Children in foster care will transition to Medicaid managed care

• The HCBS benefits of the five children’s 1915c Waivers will be aligned into one array of benefits

• A new expansion eligibility group who meet a Level of Need targeting and functional criteria will be created

• For children meeting LON and Level of Care and who do not qualify, Medicaid eligibility will be considered as a household of one without regard to parental income

• For children with Medicaid as a household of one access to HCBS benefits will be paid via fee-for-service

• The 1915c Waivers will be discontinued when the transition is complete

• Habilitative Skill Building

• Caregiver/Family Support Services

• Prevocational Services

• Supported Employment Service

• Community Advocacy and Support

• Non-Medical Transportation

• Day Habilitation

• Respite (Crisis & Planned)

• Adaptive and Assistive Equipment

• Accessibility Modifications

• Palliative Care (includes Family Palliative Care Education, Bereavement, Massage and Expressive Therapy, and Pain and Symptom Management)

• Care Coordination (for children not eligible for Health Home, CMS requires care plans for children that receive HCBS services)

Proposed Home and Community Based Services – 2017

December 8, 2015 23

Reflects “alignment” of all HCBS services available under different 1915c Waiver Programs (OMH SED, OCFS Bridges to Health & DOH Care at Home I/II)

Requires CMS Approval of 1115 Amendment for Managed Care More tools in the tool box: HCBS available to larger population of children (no

longer limited to waiver slots) Broader array of HCBS available, at the same time 1915c Waiver Programs are

discontinued

Children’s HCBS Eligibility

December 8, 2015 24

To be eligible for HCBS benefits, children must meet:• target criteria • functional criteria and• Medicaid financial eligibility

Children and youth younger than 21

• With Serious Emotional Disturbance (SED); or

• Placed in Foster Care who have SED, are Developmentally Disabled or Medically Fragile, or have experienced abuse, neglect or maltreatment; or

• Who are physically disabled and require significant medical or technological health supports; or

• With Substance Use Disorders

Children’s HCBS Target Populations

December 8, 2015 25

Children’s HCBS Functional Criteria

Level of Care (LOC)– criteria met and determined by assessment that would indicate a child is eligible for or at risk of medical institutional placement in a facility licensed by NYS OMH, Intermediate Care Facility for the Mentally Retarded (ICF/MR), or skill nursing facility/Hospital. Current criteria for children’s 1915(c) Waivers.

NEW Expansion Population: Level of Need (LON)– criteria met and determined by assessment that would indicate a child has needs that cannot be met only by non-medical institutional State Plan Services, but who does not qualify for Level of Care.

December 8, 2015 26

Both levels determined by CANS-NY (Child and Adolescent Needs and Strengths Assessment) and its algorithms.

One Array of Children’s HCBS Benefits

Managed in two ways:

Medicaid Managed Care AND

Medicaid Fee for Service program

December 8, 2015 27

Children with Community Medicaid

• Will be enrolled in Medicaid Managed Care• Can access Health Home Care Management if they

meet eligibility criteria• Can access the full array SPA services if they meet

medical necessity for any of the services• Can access HCBS benefits if they meet targeting and

LOC or LON criteria (determined by completing the CANS-NY)

December 8, 2015 28

• Excluded from Managed Care if they are eligible for Medicaid

• Comprehensive TPHI (Third Party Health Insurance) includes those with commercial coverage, dual Medicaid/Medicare or Medicaid spend down

• Children with Comprehensive TPHI have access to HCBS Waiver Services today via targeting and functional criteria (LOC) in the 1915c Waivers (OMH SED, OCFS B2H, DOH CAH I/II)

• Goal to maintain benefit availability to children meeting LOC criteria and expand to children meeting LON criteria

• If eligible for HCBS benefits, will access through separate but equal system (Fee for Service) of benefits

Children with Comprehensive TPHI

December 8, 2015 29

Role of the County/City Government in HCBS Eligibility Determination

December 8, 2015 30

New York’s goal is to maintain and expand availability of HCBS benefits for children who need them.

• Problem: Children without Medicaid cannot enroll in a Health Home, which determines HCBS eligibility

• Problem: A determination of HCBS targeting and functional criteria must be completed to enable Medicaid financial eligibility determination as a “family of one”

• Proposal Solution: Development of local Independent Entity function for “family of one” children

HCBS Eligibility Dilemmas and Proposed Solution

December 8, 2015 31

1. Establish a single phone number or physical location for children and families requesting HCBS benefits

2. The IE will • conduct a telephonic or in-person Eligibility Evaluation Screen to determine HCBS

presumptive eligibility for those children without Medicaid;• Enter the Screen question data into the Uniform Assessment System (UAS) on the NYS

DOH Health Commerce System (HCS); and• Attest to HCBS Presumptive Eligibility Determination based on target and functional criteria.

3. The IE will develop a provisional plan of care, to include the immediate HCBS benefits that could meet family needs and/or referral to Health Home

4. The IE refers the family to file a Medicaid application with LDSS (HRA) with verification of HCBS presumptive eligibility.

December 8, 2015 32

Independent Entity (IE) Functions and Responsibilities

6. The IE should verify Medicaid eligibility for those children screened until which time that Medicaid eligibility has been determined.

7. Once Medicaid eligibility is established based on family of one financial methodology, the IE should inform the family that they are provisionally eligible for HCBS benefits, the child has been determined Medicaid eligible and ask if they can be referred to Health Home for care coordination services.

8. If consent is given, the IE enters MAPP via the UAS and completes Health Home referral and transmits the HCBS Eligibility verification and Provisional Plan of Care (POC).

December 8, 2015 33

Independent Entity (IE) Functions and Responsibilities – (continued)

Provider Designation Processes

December 8, 2015 34

SPA Provider Designation Process

• Must be a licensed, certified or designated provider of OMH, OASAS, OCFS or DOH within specific parameters

• Process under development, including technical assistance for current non-Medicaid providers (Family and Youth Peers)

December 8, 2015 35

Children’s HCBS Provider Designation

• Grandfathering of current children’s 1915c HCBS providers

• Expansion of designation for current children’s HCBS providers

• Application for newly designated children’s HCBS providers

December 8, 2015 36

“Today and Tomorrow” – Expansion of Services for All Children

December 8, 2015 37

Today - 2015Tomorrow – 2017 Full Implementation

• Current State Plan Services

• Limited Array of HCBS Services (depending on Waiver program) available only to Waiver Children

• Care Coordination Under 1915c Waivers and OMH TCM Program (12,000)

• Current State Plan Services

• Six New Plan Services (2016)

• Expanded array of HCBS Services based on LON and LOC Criteria

• Health Home Care Coordination – available to significantly expanded population of children with chronic conditions

Questions?Children’s Managed Care Design

Angela Keller, LMSW

Director, Bureau of Children’s Program Design, Policy & Planning

Division of Managed Care

NYS Office of Mental Health

Angela.Keller@omh.ny.gov

Children’s Health Home or MAPP

The Health Home Team

Division of Program Development and Management

 New York State Department of Health

Office of Health Insurance Programs

(518) 473-5569

HHSC@health.ny.gov

31