MEDICAID REDESIGN TEAM: MANAGED CARE AND BEHAVIORAL HEALTH

MRT meeting of the Behavioral Health Subcommittee

  • Presentation is also available in Portable Document Format (PDF, 341KB)

May 1, 2013

Agenda

  • Welcome and Introduction
    • Guiding principles of redesign
    • Vision
  • Background
    • Existing managed care environment
    • Medicaid Redesign Team (MRT) recommendations
    • BHO 1 update
  • Behavioral Health Managed Care Program Design
    • Managed care models
    • Benefits
    • Populations and service spending
    • Quality and performance measures
    • Plan qualifications
    • Children´s update
  • Feedback and Discussion
  • Next Steps

Guiding Principles of Redesign

  • Person centered care management
  • Integration of physical and behavioral health services
  • Recovery oriented services
  • Patient/consumer choice
  • Protection of continuity of care
  • Ensure adequate and comprehensive networks
  • Tie payment to outcomes
  • Track physical and behavioral health spending separately
  • Reinvest savings to improve services for behavioral health populations
  • Address the unique needs of children, families and older adults

Vision for Behavioral Health Managed Care

Fully integrated treatment where behavioral and physical health are valued equally and patients´ recovery goals are supported through a comprehensive and accessible service system

Background

Existing Managed Care Environment

Current Managed Care Benefit Package is Irrational for Behavioral Health

TANF or Safety Net* SSI*
• Must join a health plan** • Must join a health plan**
• Health plan covers most acute care services and some behavioral health services • Health plan covers most acute care services
• Health plan provides inpatient mental health, outpatient mental health, SUD inpatient rehabilitation, detox • Health plan covers detox services
• Continuing day treatment, partial day hospitalization and outpatient chemical dependency are provided through unmanaged fee for service • All other behavioral health services are provided in unmanaged fee for service program

*HIV SNP is more inclusive of some behavioral health benefits for both SSI and Non SSI
**Unless otherwise excluded or exempted from enrolling

Medicaid Redesign Team Recommendations

  • Fundamental restructuring of the Medicaid program to achieve:
    • Measurable improvement in health outcomes
    • Sustainable cost control
    • More efficient administrative structure
  • For Behavioral Health, MRT recommended:
    • Risk-bearing, full-benefit Special Needs Plans (Health and Recovery Plans - HARPs) and/or
    • Behavioral Health Organizations (BHOs)
  • Reinvestment of savings to improve services for behavioral health populations
  • Promotion of improved behavioral health care in primary care/non-specialty settings

BHO 1 Update

Behavioral Health Phase II:
Managed Care Program Design

NY´s Design for Managed Behavioral Health

  • Behavioral Health will be managed by
    • Special needs Health and Recovery Plans (HARPs) for individuals with significant behavioral health needs
    • Mainstream managed care plans
      • Plans may operate services directly only if they meet rigorous standards
        • Plans that do not meet rigorous standards must partner with a BHO which meets standards
      • Plans can partner with BHOs to meet the rigorous standards
  • Design will enhance the array and quality of services available in all Plans
    • Existing 1115 Managed Care Partnership Plan waiver will be amended
  • All Plans MUST meet rigorous standards for managing behavioral health benefits
  • 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
  • Plans may also choose to apply to be a Health and Recovery Plan (HARP) with expanded benefits

Key Requirements for ALL Plans

  • Individual Plans of care and care coordination must be person- centered and be accountable for both in-plan benefits and non-plan services
    • e.g., housing, AOT requirements
  • Plans must interface with social service systems to address homelessness, criminal justice, and employment related issues for their members
  • Plans must interface with Local Governmental Units (LGU)
  • Plans must interface with State psychiatric centers to coordinate care for members

Health and Recovery Plans (HARPs)

  • Distinctly qualified, specialized and integrated managed care product for individuals with significant behavioral health needs
    • Distinct product line
    • Specialized Plan administration and management appropriate to the populations/services
    • Enhanced benefit package with specialized medical and social necessity/utilization review approaches for expanded recovery-oriented benefits
      • Reflected in premium
    • Integrated health and behavioral health services
    • Additional quality metrics and incentives
    • Enhanced access and network standards
    • Enhanced care coordination expectations
  • Participants must meet HARP eligibility criteria
    • Initial eligibility based on historical use
    • Future eligibility based on:
      • Functional/clinical assessment
        • (e.g., individuals with first episode psychosis)
      • Periodically updated historical utilization
  • Open enrollment in HARPS for eligible populations
    • Other strategies to facilitate enrollment being explored
  • Premiums include all Medicaid State Plan services
    • Physical Health
    • Behavioral Health
    • Pharmacy
    • Long Term Care
    • Health Home
  • Manage new 1115 waiver benefits
    • Home and Community Based 1915(i) waiver-like services
    • Not currently in State Medicaid Plan
    • Eligibility based on functional needs assessment

Benefit Package

Behavioral Health Benefit Package

Behavioral Health State Plan Services (for Adults)

  • Inpatient - SUD and MH
  • Clinic - SUD and MH
  • PROS
  • IPRT
  • ACT
  • CDT
  • Partial Hospitalization
  • CPEP
  • TCM
  • Opioid treatment
  • Outpatient chemical dependence rehabilitation
  • Rehabilitation supports for Community Residences

Enhanced Services for HARP

Workgroup recommended 1915(i)-like waiver services* - Access based on functional/clinical assessment for targeted populations

  • Services in Support of Participant Direction
    • Information and Assistance in Support of Participant Direction
    • Financial Management Services
  • Crisis
    • Crisis Respite
  • Support Services
    • Community Transition
    • Family Support
    • Advocacy/ Support
    • Training and Counseling for Unpaid Caregivers
  • Empowerment Services
    • Peer Supports
  • Service Coordination
  • Rehabilitation
    • Pre-vocational
    • Transitional Employment
    • Assisted Competitive Employment
    • Supported Employment
    • Supported Education
    • Onsite Rehabilitation
    • Respite
    • Habilitation

* Draft service definitions can be found in appendix 2

Population and Service Spending

Quality and Performance

Raising Standards for Behavioral Health Care

  • Raise the bar on behavioral health management for all members:
    • Expertise and experience, network, access, service utilization/ penetration, care coordination
    • Quality Measures "beyond HEDIS"
    • Engaging the disengaged
    • Promoting consumer engagement
  • Assure reinvestment of savings in services and supports for people with behavioral health needs
  • Ongoing monitoring by the entire behavioral health community
  • Incentive payments based on performance
  • Minimum Medical Loss Ratio (MLR) requirements

Performance Expectations

Limited metrics now in place to measure quality/outcomes for MH/SUD services and populations

  • Expanded measures for addressing behavioral health in primary care
  • Performance standards to be enhanced for MCOs and HARPs
  • Measures to be developed for newly managed MH/SUD services. Examples:
    • Improving behavioral health care including increased access
    • Follow-up post inpatient/ER
    • Service engagement
    • Medication management
    • Improving physical health
  • HARP measures additionally focus on coordination of behavioral health and primary care
    • Health Home Care Coordination/Engagement indicators
    • 1915(i)-like services and recovery metrics
      • For example: participation in employment; enrollment in vocational rehab services and education/training; housing status; community tenure; criminal justice involvement; peer service use and improving functional status
  • New metrics require data beyond claims and encounters and may need to be phased in

Plan Qualification

Plan Qualification Process

  • Request for Qualifications (RFQ) for all Plans
  • All Plans must demonstrate capacity to meet enhanced standards and manage currently carved-out services
    • Standards to be detailed in the RFQ
    • RFQ review will determine whether Plan can qualify (alone or in partnership with a BHO) or must partner with a qualified BHO
  • Plans applying to develop HARPs must be qualified via RFQ
    • HARPs will have to meet some additional program and clinical requirements which will be reflected in the premium
    • A Plan´s HARP must cover all counties that their mainstream Plan operates in

Children´s Update

Children´s Behavioral Health Workgroup

  • Shared leadership: OMH, OASAS, OCFS, DOH
  • Preliminary model approved by children´s MRT group last November
  • Model builds on existing provider network
  • Currently incorporating feedback from children´s MRT and stakeholders
  • Bridging with Adult Design work group

Children´s Workgroup: Next Steps

  • Assign work plan tasks
  • Continue work on model details
  • Ongoing consultation from Mercer (actuarial and program consultant)
  • Status update to children´s MRT on June 24

Feedback

Feedback

  • Standards for RFQ/Plan Selection
    • Standards for Selection of MCOs
    • Standards for Selection of HARPS
  • Network and Panel Standards
    • Network Requirements
    • Credentialing
    • Continuity of Care
  • Quality and Performance Measures
  • Incentive Payments
  • Service Provider Readiness
  • Other?

Next Steps

MRT BHO/HARP PHASE 2 TIMELINE

MRT Milestone Adult (NYC) Adult (Rest of State) Kids
Finalize program design Spring 2013 Spring 2013  
Finalize BHO/HARP/MCO managed care contract requirements Summer 2013 Summer 2013  
Post procurement on website for at least 30 days (per enacted legislation) Late Summer 2013 Winter 2014  
Select HARPs and Qualify Plans/BHOs for mainstream benefits Winter 2013 Summer 2014  
Plans fully operational Spring 2014 Fall 2014 Spring 2015

For a detailed MRT behavioral health work plan see http://www.health.ny.gov/health_care/medicaid/redesign/docs/project_mgmt_phase2.xls

Next Steps

  • Continue to facilitate provider readiness
  • Establish network requirements, selection criteria, evaluation/performance measures that meet Legislative requirements
  • Set rates
  • Federal approval
  • Publish RFQ requirements and qualify Plans
  • Implementation
  • Continue development of children´s design

Appendix 1: HARP Eligibility

Initial HARP Eligible Population - Mental Health

Minimum Qualifications

  • Medicaid Enrolled
  • Initially, over 20 years of age as of 2011 (Qualifying service use prior to 21st birthday is considered in qualification.)
    • Could add individuals 18-21 based on functional assessment and diagnosis
      • e.g., first episode psychosis
  • Non Medicare enrolled ("dual enrollee") in the 2009-2011 period
  • Not eligible for OPWDD managed care
  • SMI diagnosis

Other Criteria for Eligibility

  • SSI or SSI/MA only and at least one "organized" mental health Medicaid fee-for-service or Medicaid managed care service in 2011.
  • SSI individuals who did not meet the qualifications and non-SSI individuals who met the "Minimum HARP Qualifications" if they met one of the following qualifications:
    • Received three or more claims for ACT, TCM, PROS, or PMHP services in any of the 2009- 2011 years
    • Received more than 30 days of psych inpatient services in any of the last 3 years
    • Had three or more psychiatric inpatient admissions in the three years 2009 through 2011 with at least one admission in 2011
    • Were discharged from an OMH PC after an inpatient stay greater than 60 days in last year
    • Had a current or expired AOT ("Assisted Outpatient Treatment") order in 2008-2011
    • Were discharged from NYS Department of Corrections with a history of inpatient or outpatient treatment through OMH´s Central NY Psych Center in 2008-2011
    • Were residents in OMH funded Housing for persons with serious mental illness in any of the 2009-2011 years

HARP Eligible Population - Substance Use

  • 2 or more detoxification admissions (inpatient/outpatient) within 12 months (CY 2011)
  • 1 inpatient rehabilitation admission within 12 months (CY 2011)
  • 2 or more inpatient hospital admissions with primary substance use diagnosis or with SUD related DRG and a secondary substance use diagnosis within 12 months (CY 2011)
  • 2 or more emergency department visits with primary substance use diagnosis or primary non-substance use/related secondary substance use diagnosis within 12 months (CY 2011)

Future Eligibility

  • Future pathways to HARP enrollment
    • Individual identified based on functional/clinical assessment
    • Individual identified by the Local Governmental Unit (LGU)
      • Individuals would still need to be functionally assessed
    • Periodic review of historical Medicaid utilization

Appendix 2: 1915(i) Like Service Definitions

1915(i) Like Service Definitions

Advocacy/ Support:

HCBS family support and training/ peer support services. Advocacy/support services may be individual advocacy or systems advocacy (or a combination of both. Examples are warm lines, hot lines, teaching daily living skills, providing representative payee services, and training in any aspect of mental health services. Individual advocacy assists consumers in protecting and promoting their rights, resolving complaints and grievances, and accessing services and supports of their choice. Systems advocacy represent the concerns of a class of consumers by identifying patterns of problems and complaints and working with program or system administrators to resolve or eliminate these problems on a systemic, rather than individual basis.

Assisted Competitive Employment:

The objective of this service is to assist individuals in choosing, finding, and maintaining satisfying jobs in the competitive employment market at minimum wage or higher. When appropriate, ACE provides these individuals with job related skills training as well as long-term supervision and support services, both at the work site and off-site.

Community Transition:

Community transitions services are non-recurring set-up expenses for individuals who are transitioning from an institutional or another provider-operated living arrangement to a living arrangement in a private residence where the person is directly responsible for his or her own living expenses. Allowable expenses are those necessary to enable a person to establish a basic household that does not constitute room and board and may include: (a) security deposits that are required to obtain a lease on an apartment or home; (b) essential household furnishings and moving expenses required to occupy and use a community domicile, including furniture, window coverings, food preparation items and bed/bath linens; (c) set-up fees or deposits for utility or service access, including telephone, electricity, heating and water; (d) services necessary for the individual´s health and safety, such as pest eradication and one-time cleaning prior to occupancy; (e) moving expenses; (f) necessary home accessibility adaptations and (g) activities to assess need, arrange for and procure need resources. Community transition services are furnished only to the extent that they are reasonable and necessary as determined through the service plan development process, clearly identified in the service plan and the person is unable to meet such expense or when the services cannot be obtained from other sources. Community transition services do not include monthly rental or mortgage expense, food, regular utility charges and/or household appliances or items that are intended for purely diversional/ recreational purposes.

Crisis Respite:

Crisis Respite is a short term care and intervention strategy for a participant experiencing a crisis of behavioral well-being for which a period of structured support and/or programming is required to alleviate shocks or stresses. Crisis Respite may be used when acutely challenging, dangerous, or potentially life threatening behaviors are occurring and all other approaches to ensure health and safety have failed. In addition, the service may be used as a planned respite stay for persons who are unable to access regular respite due to the nature of their behaviors, according to the admission requirements of the center. Crisis respite is offered for periods of short duration and is not to be utilized as a housing substitute. Crisis respite centers offer peer support, either on-site or as a wrap-around service during the respite stay. At the conclusion of a crisis respite period, clinical staff will make a determination as to the continuation of care necessary and make a recommendation to the person(s) in charge of the recipients´ plan of care.

Family Support:

Training and counseling services for the families of individuals served on this waiver. For purposes of this service, "family" is defined as the persons who live with or provide care to a person served on the waiver, and may include a parent, spouse, children, relatives, foster family, or in-laws. "Family" does not include individuals who are employed to care for the consumer. Training includes instruction about treatment regimens and use of equipment specified in the plan of care, and shall include updates as necessary to safely maintain the individual at home. All family training must be included in the individual´s written plan of care. Allowable activities include:

  • Treatment regimens and use of equipment
  • Stress management
  • Parenting
  • Family dynamics
  • Community integration
  • Behavioral intervention strategies
  • Mental health
  • Caring for medically fragile individuals

Financial Management Services:

Service/function that assists the family or participant to: (a) manage and direct the disbursement of funds contained in the participant-directed budget; (b) facilitate the employment of staff by the family or participant, by performing as the participant´s agent such employer responsibilities as processing payroll, withholding federal, state and local tax and making tax payments to appropriate tax authorities and (c) performing fiscal accounting and making expenditure reports to the participant or family and state authorities.

Habilitation:

Services designed to assist participants in acquiring, retaining and improving the self- help, socialization and adaptive skills necessary to reside successfully in home- and community-based settings.

Information and Assistance in Support of Participant Direction:

Service/function that assists the participant (or the participant´s family or representative, as appropriate) in arranging for, directing and managing services. Serving as the agent of the participant or family, the service is available to assist in identifying immediate and long-term needs, developing options to meet those needs and accessing identified supports and services. Practical skills training is offered to enable families and participants to independently direct and manage waiver services. Examples of skills training include providing information on recruiting and hiring personal care workers, managing workers and providing information on effective communication and problem solving. The service/function includes providing information to ensure that participants understand the responsibilities involved with directing their services. The extent of the assistance furnished to the participant or family is specified in the service plan. This service does not duplicate other waiver services, including case management.

Onsite Rehabilitation:

The objective is to assist individuals disabled by mental illness who live in adult congregate care settings, supervised or supported living arrangements to achieve their treatment and community living rehabilitation goals. Services include one or a combination of: consumer self-help and support interventions, community living, academic and/or social leisure time rehabilitation training and support services. These services are typically provided either at the residential location of the resident or in the natural or provider-operated community settings which are integral to the life of the residents. These on-site rehabilitation services are provided by a team that is either located at the residential site or which functions as a mobile rehabilitation team traveling from site to site.

Peer Supports:

Peer services are administered by a trained individual who has personal experience with a mental health diagnosis. Peers are determined by a clinical professional to be capable of assisting recipients of mental health care in the recovery process. Services administered by peers will assist individuals to identify and plan to fulfill their personal interests in life, explore and realize opportunities for community participation, pursue social and recreational opportunities, maintain a physically healthy lifestyle, and to more actively take charge of their own life. The goal is to help individuals realign their personal vision of the future toward a lifetime of personal goal achievements, rather than one dominated by feelings of disability and resignation.

Pre-vocational:

Services that prepare a participant for paid or unpaid employment. Services include teaching such concepts as compliance, attendance, task completion, problem solving and safety. Services are not job-task oriented, but instead, are aimed at a generalized result. Services are reflected in the participant´s service plan and are directed to habilitative rather than explicit employment objectives. Meals provided as part of these services shall not constitute a "full nutritional regimen" (three meals per day).Documentation is maintained in the file of each individual receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.).

Respite:

Services provided to participants unable to care for themselves that are furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the participant. Federal financial participation is not claimed for the cost of room and board except when provided as part of respite care furnished in a facility approved by the State that is not a private residence.

Supported Education:

The objective of this program is to provide mental health and rehabilitation services to individuals with a serious mental illness to assist them to develop and achieve academic goals in natural and community-based educational settings. The emerging program models for delivering this service include free-standing career-development and exploration programs housed on college campuses, ongoing counseling and support by a mental health provider to enrolled students, and collaborative relationships between mental health and on-campus services to students with disabilities. Funding is to cover mental health staff and related costs.

Supported Employment:

Supported employment services consists of intensive, ongoing supports that enable participants for whom competitive employment at or above the minimum wage is unlikely, absent the provision of supports, and who, because of their disabilities, need supports to perform in a regular work setting. Supported employment may include assisting the participant to locate a job or develop a job on behalf of the participant. Supported employment is conducted in a variety of settings, particularly work sites where persons without disabilities are employed. Supported employment includes activities needed to sustain paid work by participants, including supervision and training. When supported employment services are provided at a work site where persons without disabilities are employed, payment is made only for the adaptations, supervision and training required by participants receiving waiver services as a result of their disabilities but does not include payment for the supervisory activities rendered as a normal part of the business setting. Documentation is maintained in the file of each participant receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.).Federal financial participation is not claimed for incentive payments, subsidies or unrelated vocational training expenses, such as the following: Incentive payments made to an employer to encourage or subsidize the employer´s participation in a supported employment program Payments that are passed through to users of supported employment programs Payments for training that is not directly related to an individual´s supported employment program.

Training and Counseling for Unpaid Caregivers:

Training and counseling services for individuals who provide unpaid support, training, companionship or supervision to participants. For purposes of this service, individual is defined as any person, family member, neighbor, friend, companion or co-worker who provides uncompensated care, training, guidance, companionship or support to a person served on the waiver. This service may not be provided in order to train paid caregivers. Training includes instruction about treatment regimens and other services included in the service plan, use of equipment specified in the service plan and includes updates, as necessary, to safely maintain the participant at home. Counseling must be aimed at assisting the unpaid caregiver in meeting the needs of the participant. All training for individuals who provide unpaid support to the participant must be included in the participant´s service plan.

Transitional Employment:

The objective is to strengthen the individual´s work record and work skills toward the goal of achieving assisted or unassisted competitive employment at or above the minimum wage paid by the competitive sector employer. TEP´s provide time-limited employment and on-the-job training in one or more integrated employment settings as an integral part of the individual´s vocational rehabilitation growth.