Implementing Medicaid Behavioral Health Reform in New York

June 3, 2014

Redesign Medicaid in New York State

NYSRA-NYSACRA Community Integration Leadership Institute: Advancing Outcomes

Agenda

Overview of BH Transition to Managed Care

BHO Phase 2 Status

Behavioral Health Managed Care Transition Timeline

RFQ Standards

Next Steps

2

BH Transition to Managed Care

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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

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

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

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

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)

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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

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9

BHO Phase 2 Status

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BHO Phase 2 Status

Revised RFQ based on RFI comments

RFQ distributed (with draft NYC HARP rates) on March 21, 2014

OMH: http://www.omh.ny.gov/omhweb/bho/phase2.html

DOH: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health_transition.htm

RFQ Applicant’s Conference held on May 2, 2014 in NYC

NYC Applications due June 6, 2014

Rest of State - approximately six months later

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Behavioral Health Manged Care Transition T imeline

NYC implementation 1/1/15

2/11/2014

POST RFQ EARLY TO MID MARCH

PLAN RESPONSES DUE

BEGIN MEMBER NOTIFICATION OF

HARP PASSIVE ENROLLMENT*

NYC IMPLEMENTATION

1 Feb 1 Mar 1 Apr 1 May 1 Jun 1 Jul 1 Aug 1 Sep 1 Oct 1 Nov 1 Dec 1 Jan 1 Feb 1 Mar

State review /designation and revision as needed--NYC RFQ responses6/1/14-10/1/14

NYC Plan Readiness Review 8/29/14-11/1/14

Statew ide MC-Providerstart-up assistance ($20M)*

NYC Final rates availableApril 2014

Building statew ide capacity for 1915(i)-like services begins 10/1/14** ($30M)

*Statewide MC-Provider start-up:- Funds to ensure adequate networks are in place prior to implementation of BH MC - Plan/Provider/HH technical assistance for electronic medical records and billing- Funds to build BH provider (Children and Adults) infrastructure

**Building statewide 1915(i)-like service capacity involves: - 1915(i)-like network development- Funding 1915(i)-like functional assessments - Funding for 1915(i)-like services starting January 1, 2015

InterRAI functional assessment tool pilot 5/1/14-7/1/14

Public Notice of OASAS SPA (3/5/14)

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RFQ Standards

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RFQ Performance Standards

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

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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.

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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

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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

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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

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

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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

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

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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

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

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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

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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

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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

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

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Next Steps

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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

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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)

Next Steps

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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