Health and Recovery Plan (HARP)/ Behavioral Health Archive

Transitioning Office of Mental Health Children´s Targeted Case Management (TCM) Program to Health Homes

  • Studies is also available in Portable Document Format (PDF)

Webinar #2: TCM Legacy Rate and Enrollment of TCM Children into Health Homes

August 24, 2015
1 pm – 3 pm

Introductions

  • Michelle Wagner, Division of Integrated Community Services for Children and Families, OMH
  • Angela Keller, LMSW, Director, Bureau of Children´s Program Design, Policy & Planning Division of Managed Care, OMH
  • Lana I. Earle, Deputy Director, Division of Program Development and Management, Office of Health Insurance Programs, NYS DOH

Today´s Discussion

Update: Implementing Health Homes for Children

  • Webinar #1 for TCM providers June 8, 2015
  • June 15, 2015 – Health Home Designations Announced
    • ✓ 16 Health Homes Contingently Designated to Serve Children
      • 12 adult Health Home expanding to serve children, 4 new children´s Health Homes
      • Every county has at least two designated Children´s Health Homes
      • List of Designated Health Homes Serving Children included in appendix of this Webinar and can be found here.
    • ✓ All 16 accepted designations and have agreed to address contingencies, including:
      • Expanding their network to include existing OMH TCM providers and other providers with expertise in providing care management to children (e.g., other Waiver providers)
        • Ensures continuity of care/smooth transition for children receiving existing care management services that will transition to Health Home and builds capacity of knowledgeable care management providers
        • Designated Children´s Health Homes will be contacting TCM providers - TCM providers may also directly contact Designated Health Homes
      • Certify ability to pay downstream care managers
      • Clarification on approach to tailor services or governance structure
    • ✓ Contingency responses due back to State Team on August 17
Anticipated Schedule of Activities for Expanding Health Homes to Better Serve Children Due Date
Draft Health Home Application to Serve Children Released June 30, 2014 – Completed
Due Date to Submit Comments on Draft Health Home Application to Serve Children July 30, 2014 – Completed
Due Date to Submit Letter of Interest July 30, 2014 – Completed
Final Health Home Application to Serve Children Released November 3, 2014 – Completed
Due Date to Submit Health Home Application to Serve Children March 2, 2015 – Completed
Review and Approval of Health Home Applications to Serve Children by the State Health Homes Designated (Contingently) to Serve Children: http://devweb.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_children/ March 2, 2015 to June 15, 2015 – Completed
HH and Network Partner Readiness Activities June 15, 2015 to December 31, 2015
State Webinars, Training and Other Readiness Activities Through December 2015
Begin Phasing in the Enrollment of Children in Health Homes January 2016
Children´s Behavioral Health Services and other Children´s Populations Transition to Managed Care January 2017 (NYC/LI)/ July 2017 ROS
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OMH Health Home Care Management Legacy Slots

  • For all TCM providers, the legacy slots are determined by dividing the total Medicaid claims billed during CY 2013 by 12 months.
  • TCM providers will be notified of their Legacy Slots (LGU and SPOA will be included in notification)

OMH Health Home Care Management Legacy Rates

  • Legacy rates will be calculated for each provider using Medicaid claims data for Calendar Year 2013 to determine average caseload and average Medicaid rate per case per month (based on the rates in effect as of April 1, 2013).
  • For TCM providers of only one type of case management service, the rate is simply the rate in effect for that service type (ICM, SCM or BCM).
  • For TCM providers of more than one type of case management services, the rate is total billable dollars divided by total Medicaid claims paid.
  • TCM providers will be notified of their Legacy Rates (LGU and SPOA will be included in notification)

General Framework: Transitional Health Home for Children Per Member Per Month (PMPM) Rate Provisions for Legacy OMH TCM Providers

  • OMH TCM Providers will be subject to Children´s Health Home (HH) Per Member Per Month (PMPM) Rates
    • For many OMH TCM providers, the proposed HH PMPM for children are higher than current OMH TCM rates
    • The HH PMPM rates will be based upon the "case mix" of children by applying the HH algorithm to the CANS–NY tool to determine the HH acuity levels, i.e., High, Medium, or Low HH PMPM rates for children
  • Payments received under the HH, PMPM rate structure will be reconciled by comparing what an OMH TCM provider would have received under an OMH TCM Legacy Rate to what it received from the HH PMPM rates
    • Providers that received less than HH PMPM payment than they would have received under legacy slots, as calculated below, will receive a legacy payment
  • The reconciliation process allows for consistent billing and payment procedures across Health Homes, while also ensuring children´s OMH TCM providers receive a level of funding that is comparable to what was received prior to the implementation of Health Homes

Health Home Rates for Children (under 21)

  Per Member Per Month HH Care Management Rates
Acuity (CANS Algorithm) Case Load Ratios Not Mandated Upstate Downstate
HFW (1:10 – Pilot Demo) $900 $958
High (1:12) 750 799
Medium (1:20) 450 479
Low (1:40) 225 240
Outreach 135 135
CANS–NY Assessment 185 185

Reconciliation of HH PMPM Rate and Legacy Rates

  • Reconciliation will occur quarterly
  • All members in outreach or enrollment status will be included in the reconciliation
  • The assessment fee will be included in the Health Home payments when compared to the OMH TCM Legacy payment
  • If no assessment has been completed for an enrolled member and the member is in enrollment status, the HH rate will be considered as "low" for that month. This process will only be allowed for month 1 & 2; if provider has not completed assessment by month 3 they may not bill the HH rate. The month with no billing will not be included in the reconciliation.
  • If a program does not fill all their legacy slots, the reconciliation of payments will compare only the OMH TCM filled legacy slots
  • Any slots filled over legacy slots will not be included in the reconciliation – this will be considered new business
  • If the number of HH members is at or above the OMH TCM legacy slot capacity, the program will be considered "whole" if the program received Health Home rates at or above the OMH TCM legacy rate for the TCM legacy slot capacity
  • Initially, DOH will begin the reconciliation process ten days following the close of a calendar quarter. If it is determined that insufficient data is in the system ten days following the close of a quarter, DOH/OMH will determine the appropriate timeframe to complete the reconciliation within the close of a future quarter
  • DOH/OMH will monitor and reconcile HH payments for two years. DOH/OMH reserve the right to suspend legacy reconciliation earlier if the legacy TCM conversion is fiscally stable. Providers will be given at least one quarter´s notice in the event of early suspension.
  • Monthly monitoring will occur by the State of each providers´ billing revenue; individual outreach to TCM agencies on cash flow and fiscal standing will occur.

Reconciliation Example (1)

  • Provider A has a TCM legacy rate of $500 and a legacy slot cap of 20
  • All 20 legacy slots are full
  • At completion of CANS–NY, 5 children are high acuity, 8 score medium acuity and 5 are rated low acuity. Of these children, 6 CANS–NY assessments were completed in the quarter.
  • Care managers are in the process of completing CANS–NY assessments for one child and conducting outreach for another child
Legacy Slot Cap Filled HH Slots Legacy Rate Actual CANS Acuity for Children in Legacy Slots (completed assessment $185) Children in Outreach Status ($135 PMPM) Children with Consent Signed but CANS–NY incomplete (bill L $225)
20 20 $500 5 – high acuity
8 – medium acuity
5 – low acuity
6 assessments were completed this quarter.		 1 1 – low acuity
Quarter´s Health Home PMPM against legacy cap [3× {(5×750=) + (8×450=) + (5×225=)}] + (6×185=) + 135 + 225 = $26,895
Legacy Average for Quarter = $30,000
Reconciliation Payment due Agency: $3,105

Reconciliation Example (2)

  • Provider B has a legacy rate of $500 and a legacy slot cap of 50
  • All 50 legacy slots are full
  • Provider B is serving an additional 50 children (new business)
  • At completion of CANS–NY, 25 children are high acuity, 35 are medium acuity and 42 are rated low acuity. Of these children, 10 CANS–NY assessments were completed in the quarter.
Legacy Slot Cap Filled HH Slots Legacy Rate Actual CANS Acuity for Children in Legacy Slots (completed assessment $185) Children in Outreach Status ($135 PMPM) Children with Consent Signed but CANS–NY incomplete (bill L $225)
50 100 $500 25 – high acuity
35 – medium acuity
42 – low acuity
10 assessments were completed this quarter.		 5 3 – low acuity
Quarter´s Health Home PMPM against legacy cap [3× {(25×750) + (25×450) + (10×185)}] = $91,850
Legacy Average for Quarter = $75,000
Reconciliation Payment due Agency: $0

Billing Procedures

  • As of January 1, 2016, there will be no direct billing conducted by any adult or children TCM legacy providers (former COBRA, MATS, OMH and CIDP providers)
  • On January 1, 2016, the statewide process of all Health Home billing will be conducted through the Health Home and/or Plan.
    • For Children enrolled in Plans (nearly all HH eligible children): the Plan will use billing information provided in MAPP to bill the State and make payment to the Health Home, who will make payments to its downstream care managers (including OMH TCM providers)
    • For Children enrolled in Fee for Service Medicaid: Health Home will use billing information provided in the MAPP to bill the State; HH pays the downstream care managers (including OMH TCM providers)
    • All Health Homes are required to certify, on or before October 1, 2015 they have systems in place to make timely payments received from the Plan or directly from the State to downstream providers

OMH State Aid Funding

  • OMH will continue to provide LGUs with the same amount of State Aid previously given for the TCM program to be used towards providing care coordination to children with SED that are not Medicaid eligible, and thus cannot be enrolled in Health Home.
  • OMH will continue to provide LGUs with the same amount of service dollar funding previously given for the TCM program. These service dollars may be expended only for children with SED (Medicaid and Non–Medicaid), not the general HH population a TCM program may serve.
  • The amount of State Aid each provider receives will continue to be at the discretion of the LGU.

Questions?

Medicaid Analytics Performance Portal (MAPP)

Medicaid Analytics Performance Portal (MAPP)– performance management system to support providing care management for the Health Home Population

  • Portal for external referrals (LGU/SPOA, LDSS)
  • Member tracking – identification, assignment, consent management
  • Care Coordination – CANS–NY assessment and algorithm housed in MAPP
  • Analytic & Performance Management
  • Interoperability – file exchange

MAPP Functionality for Children

  • CANS–NY Assessment tool will be integrated into MAPP
  • Billing, rate information and CANS–NY algorithms (High, Medium, Low)
  • Referral portal
    • Community referrals by LGU/SPOAs, LDSS and eventually others, for Assignment
    • Direct Referrals by Health Homes, Managed Care Plans, Care Managers for Assignment
  • Will assist with managing consent to refer, enroll, and share information

Access to MAPP

  • MAPP will be launched shortly for adult model
  • MAPP will be modified (as described in previous slide) for children
  • Training specific to Health Home for Children providers (Health Homes, Plans, care managers) will be available later this Fall, prior to January 1, 2016 launch
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Enrollment of Legacy Clients into Health Homes by OMH TCM Legacy Providers

  • TCM legacy providers may begin to gather CANS–NY supporting documentation in December, so as MAPP becomes live providers can input all legacy clients into the MAPP and complete a CANS–NY assessment in January 2016
  • Each TCM legacy provider will enter its clients into MAPP for assignment to the appropriate Health Home, given alignment of contracts with Health Home and Health Homes with the members´ Plans. The child will remain with the same care management agency (OMH TCM legacy provider).
  • Parental choice could impact assignment to a Health Home.

Role of SPOA with TCM Legacy

  • Until legacy slots are phased out, SPOA will continue to manage and triage the most needy children being referred in the county
  • Once a child is determined, by SPOA, to need care coordination services a direct referral to the TCM provider may be made if the SPOA determines that the TCM expertise may be the best for the child.
  • SPOA will also have the ability to directly refer via the MAPP portal when another care management assignment is recommended.
  • If the SPOA refers the child to the OMH TCM Legacy provider, the provider in turn processes the referral into the Medicaid Analytic Performance Portal (MAPP) as per protocols

Future Webinars to Facilitate TCM Transition to Health Home

  • OMH TCM Webinar #3 will provide information on Agency Preparedness and Administrative Processes
  • DOH Statewide Webinars regarding the implementation of Health Homes for Children
  • OMH will be holding a "Q&A on OMH TCM Legacy Rates" webinar on Wednesday, September 16th from 1 PM–2:30 PM.

CANS–NY Training

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Next Steps for TCM Children´s Providers

  • Establish Relationships with Health Homes and entities that have been designated to serve children
  • Actively participate in webinars and review information
  • Consider how you can maximize your expertise and the opportunities provided by the new Health Home model
  • Consider serving a broader children´s population than you currently serve
  • Completion of CANS training and certification for all program staff and their supervisors. On line training: https://canstraining.com/login

Resources for Updates

Contact Information

OMH Community TCM for Children

Michelle Wagner: Michelle.Wagner@omh.ny.gov
Phone– 518–474–8394

DOH Health Home for Children

Erin Weaver
Phone– 518–402–7841
Email– hhsc@health.ny.gov
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