Redesign Medicaid in New York State

Implementing Medicaid Behavioral Health Reform in New York

• Presentation is also available in Portable Document Format (PDF, 1MB)

MRT Behavioral Health Managed Care Update

February 26, 2014

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Agenda

• Introductions (15mins)
• BHO Phase 1 Summary (15mins)
• Updated BH MC Transition Timeline (10mins)
• Revisit Principles of BH MRT (5mins)
• RFI comment themes/State Actions and Discussion (1hr 30mins)
• Performance Management Update (10mins)
• Rate Setting Update (10mins)
• Children's Update (10mins)
• Integrated Licensing Update (5mins)
• Next Steps and Discussion (10mins)

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BHO Phase 1: Summary

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BHO Phase 2: Timeline

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Behavioral Health Managed Care Transition Timeline

Timeline Illustration

NYC Implementation 1/1/15
3/1/14	POST RFQ EARLY TO MID MARCH
3/5/14	Public Notice of OASAS SPA
4/1/14	NYC Final rates available
5/1/14 - 7/1/14	InterRAI functional assessment tool pilot
5/1/14 - 4/1/15	Statewide MC-Provider start-up assistance ($20M)*
6/1/14	PLAN RESPONSES DUE
6/1/14 - 10/1/14	State review /designation and revision as needed--NYC RFQ responses
8/29/14-11/1/14	NYC Plan Readiness Review
10/1/14	BEGIN MEMBER NOTIFICATION OF HARP PASSIVE ENROLLMENT*
1/1/15	NYC IMPLEMENTATION
10/1/14** ($30M)	Building statewide capacity for 1915(i)-like services begins

^*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

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BHO Phase 2: Project Update

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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

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BHO Phase 2 Update

• Processed RFI comments
  • Received RFI comments received from 48 entities: Plans, Providers, Advocacy Groups, Local Governments, and other Stakeholders
  • All comments logged and sorted into three categories
    • Possible change to RFQ; No change; Update guidance documents
  • Common themes were identified across submissions
• Post RFQ early March
• Final Rates in April

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Common RFI Themes

• Plan experience/ Staffing Flexibility
• Health Homes/Plan Care Management Roles and Responsibilities
• 1915(i) Home and Community Based Services
• Accommodating BH Services in Managed Care
• Utilization Management
• Network Services
• Information Technology Requirements
• Provider Reimbursement/Claims Administration
• Performance Management
• Regulatory Flexibility

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Plan Experience/ Staffing Flexibility

RFI Comments	Proposed State Action
Allow sharing of staff between MCO and HARP and have SAME staffing standards	RFQ maintains requirements for a HARP Psychiatric Medical Director and Clinical Director pending size of HARP All other positions can be shared between mainstream and HARP so long as staff has training and knowledge of HARP services Plans must identify interdisciplinary staffing team approach (ex. PH, BH, Clinical) Plans must identify individual(s) with primary authority and responsibility for management of mainstream behavioral health and HARP product line Plans must provide a distribution of BH staff and hours between mainstream and the HARP
Focus on key staff experience more than organization experience	Allow Plans not meeting experience requirements to provide proposed recruitment plan to hire in expertise or subcontract with BHO This experience will be verified during readiness reviews
Plan should have flexibility on staff to member ratio (small/rural Plans)	Allow greater flexibility for Plans with smaller HARP population Require plans to describe how their proposed staffing ratios assure timeliness of customer service, utilization management and adequacy of clinical support

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Health Homes/Plan Roles and Responsibilities

RFI Comments	Proposed State Action
Building HH capacity for HARP enrollees	NYS will work with HH and Plans to build this capacity
Clarify roles of HH versus Plans (beyond that which is already in the existing HH/Plan agreement)	NYS and Plans will explore the necessity of a formal HH delegation agreements to supplement existing contract requirements State working with Plans and HH to develop clarity around care management roles and functions. General expectation: HH provide "boots on the ground" care coordination and person centered plans of care including connection to non-Medicaid Services Plans (1) use data to identify individuals in need of high touch care management; (2) identify patients disconnected from care; (3) notify HH when members show up in ERs and inpatient; (4) monitor HH performance
Adjust 15 day HH enrollment period for HARP members	Establish Year 1 realistic time-frame
Need to develop and share metrics on HH performance	NYS will work with Plans and HH to collect and analyze HH performance

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1915(i) Home and Community Based Services

RFI Comments	Proposed State Action
Concerns about the predictability of cost and volume	NYS will initially use a non-risk payment model with individual service cost limits to build 1915(i) services NYS will provide an upfront investment to fund these services Service costs will likely move into capitation in Year 3
NYS should provide guidance on 1915(i) services and appropriate staff	NYS will develop guidance documents to clarify services, procedure coding, pricing, staffing and data reporting
NYS should qualify 1915(i) providers	NYS will develop a designation process to identify providers qualified to deliver HARP 1915(i) HCBS services Start with OMH/OASAS providers in good standing Plans will be able to supplement this provider roster with additional providers meeting equivalent qualifications and training
Make the collection of HCBS Assurances/ Sub-Assurances less burdensome	CMS requires data and outcome metrics on all HCBS services NYS working to streamline assurances/sub-assurances Need CMS approval
Developing 1915(i) HCBS assessments and plans of care	NYS is working with the University of Michigan to pilot test an InterRAI assessment tool, develop scoring, and to project cost of utilization This pilot will begin in May

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Accommodating BH Services in HARP and Mainstream

RFI Comments	Proposed State Action
Service center staff should know the services in the geographic area of the enrollee	Require Plans to provide the State with the proposed member services and utilization management training plan
Member Services Center	RFQ will clarify that Plans are not required to have a separate BH service center Centers must be appropriately staffed to handle volume, operate 24/7, and have culturally competent staff. Center staff must receive training on HARPs and be knowledgeable about local populations, crisis services and local service systems
Process for care coordination for individuals not in Health Homes	State will determine the care management model for HARP members and HARP eligibles that are not enrolled in HHs
Have Plans identify how they will integrate care for BH populations	RFQ will require Plans to detail how they plan to support integrated and collaborative care RFQ will require Plans to demonstrate the capacity to perform team-based (PH/BH) care coordination. Plans will need to indicate how they will incorporate HH care managers into the care coordination process when appropriate

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Utilization Management

RFI Comments	Proposed State Action
Allow plans flexibility related to geographic location for UM staff	Plans must demonstrate in the RFQ that out-of-state or in-state UM staff has NYS BH expertise including: Knowledge of covered services Knowledge of NYS managed care rules Knowledge of approved BH UM criteria Knowledge of approved 1915(i) rules and requirements
UM criteria need to reflect 1915(i)HCBS services	NYS will describe principles for level of care guidelines that Plans must follow UM requirements for 1915(i) services need to ensure that the person centered plan of care meets individual needs NYS will review and approve all Plan level of care guidelines for 1915(i) services

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Network Services

RFI Comments	Proposed State Action
Require Plans to contract specifically for after hours and weekend services	Plans will be required to ensure access to after-hours and weekend BH services
Require Plans to contract with clinics holding integrated licenses	Integrated BH/PH licenses is an MRT initiative Plans that contract with entities with integrated licenses will be required to contract for all services provided under that license
Modify BH network requirements to include jail/prison discharges	Network access standards for individuals with a BH diagnosis discharged from jail/prison will be similar to those discharged from hospital

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IT Requirements

RFI Comments	Proposed State Action
Require Plan and Provider connectivity to Regional Health Information Organizations (RHIOs)	RHIO connectivity is part of a broader discussion beyond HARPs If Plans are required to join RHIOs, HARPs will also be required to join The RFQ places no additional RHIO requirements on Plans and providers
Plans should facilitate the exchange of electronic information	Plans must identify how they intend to exchange data with the HH Plans must describe how they will maximize data exchange and IT connectivity with providers
NYS/ Plans should fund Health Information Technology (HIT) for providers (including EHR)	NYS will provide assistance on HIT with start up funding contingent upon sufficient funding within the adopted State budget
Facilitate telemedicine technology	NYS supports telemedicine where appropriate NYS will require Plans to provide training for providers on telemedicine technology and rules

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Provider Reimbursement/Claims Administration

RFI Comments	Proposed State Action
Allow providers that wish to negotiate alternative payment arrangements with plans to do so	Alternative Plan/provider payment arrangements will be considered on a case-by-case basis based on a mutual consensus of Plans, providers, and State These arrangements must further the BH transformational goals of the State and benefit members receiving services
Facilitate access and reimbursement for telemedicine	The RFQ language will allow Plans flexibility to pay for services using telemedicine consistent with Federal standards
Facilitate provider claims submission for new BH services	State will work with Plans and providers to develop a cohesive claims submission process for BH services 1915(i) services will be identified with distinct codes
Require web based claiming (not all Plans indicated that they accept web based claims)	The RFQ will require that plans accept web-based claims

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Performance Management Update

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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
  • Development of a limited number of new behavioral health measures
  • New measures can be derived from claims and encounter data
  • BHO Phase 1 measures will continue to be run administratively
  • Measures are also being proposed for HARPs that are based on data collected from 1915(i) eligibility assessments. These measures are related to social outcomes - employment, housing, criminal justice, social connectedness, etc;
• 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

Proposed 1915(i) Performance Measures

Social outcomes measures for the HARP Population to be collected from the 1915i Screening Tool (Tool Still in Development-based on InteRAI Assessment tool)
Domain	Performance Metric	Baseline Items and Method of Collection
Employment/Education	% of members who maintained or improved employment status or education seeking status	Employment/student status through 1915i eligibility assessment
Housing	% of members with improved housing status	Housing status through 1915i eligibility assessment
Criminal Justice	% of members with reduced arrests	Arrests in past six months through 1915i eligibility assessment
Drug and Alcohol Use	Change in Abstinence–Alcohol and Other Drug Use Recommend using for only those with a diagnosis of SUD	Substance used and frequency through 1915i eligibility assessment
Social Connectedness	% of members with improved social engagement in the past 30 days	Social engagement status through 1915i eligibility assessment
Overall Improvement in Functional Status	% of members with improved levels of functioning from baseline measurement to 12 months Member perception of positive change: deal with daily problems, better control of life; better dealing with crisis, get along with family, symptoms improved)	MHSIP survey

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Mainstream Plan Quality Incentives and Behavioral Health

• Current mainstream Plan QI methodology
  • Uses 30 HEDIS measures, including three behavioral health measures
• Recommend:
  • BH measures should include all HEDIS BH measures; and
  • Additional two or three non-HEDIS metrics deemed useful by OMH/OASAS (and agreed to by DOH)
• Under consideration for mainstream Plans:
  • Bifurcate the mainstream QI award
  • Award a percentage of the existing performance pool (more than $200M) separately based on behavioral health measures

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Proposed HARP P4P Initiative

	P4P Withhold
Year 1	0.0%
Year 2	1.0%
Year 3	1.5%
Ongoing	2.0%

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Integrated Licensing Update

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Integrated Licensing Update

• Status:
  • Seven agencies in pilot, 15 clinic sites approved
  • New rate codes for integrated services sites
  • Physical plant standards in development
  • Inter agency inspection visits conducted
  • Ongoing feedback and evaluation process
• Next steps: development of uniform, cross agency regulations for the operation of sites providing integrated behavioral health and physical health services to expand initiative statewide
• Target for statewide roll-out is January 2015

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Rate Setting Update

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Rate Setting Update

• HARP rate does not include 1915(i) services in first year
• BH and HARP MLR - percentage under development
• 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

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Children´s Managed Care Update

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Principles of Children´s Medicaid Service System

• Integrate physical and behavioral health services within mainstream Medicaid Managed Care Plans
• Care Management for All:
  • Every child that receives Medicaid will be enrolled in a high-quality, fully integrated care management program
  • Care management will be provided through a range of care management models including Managed Care Plans, Patient Centered Medical Homes and Health Homes
  • Children with the highest levels of special needs, who meet the criteria, will be enrolled in Health Homes
• Plans will be required to contract with behavioral health, foster care agencies, and specific community based providers
• Plans will contract with pediatric health care and specialty health care providers already in network
• Children and their families will be involved throughout a variety of systems
• Plans will be required to develop and maintain working relationships with school districts, non-Medicaid funded community services and supports, Regional Planning Consortiums and local government.

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Proposed 2016 Children´s Medicaid Managed Care Model

Proposed Model

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New York State Health Home Model for Children

Model for Children

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Status

• Currently, work is focusing on:
  • Finalizing the Children's benefit package
  • Setting eligibility for 1915i services
  • Investigating High Fidelity Wraparound
  • Creating mechanisms to increase the delivery of evidence-based practices
• Implementation scheduled for January 1, 2016

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Next Steps

• MRT BH Workgroup by to submit final comments by Friday 2/28/14
• State will conduct a survey to identify potential 1915(i) providers
• NYS will develop a Regulatory Reform Workgroup
• Post RFQ early March with draft rates
• Final Rates in April
• 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)

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Appendix 1:Behavioral Health QARR Metrics

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Behavioral Health QARR Metrics

Start Year	Method (A=Administrative)	Domain	Measure Name	MCO	HARP	Specifications to Use
1	A	Psychiatric Medication Management	Antidepressant Medication Management	Y	Y	HEDIS
1	A	Psychiatric Medication Management	Adherence to Antipsychotic Medications for People with Schizophrenia	Y	Y	HEDIS
1	A	Preventive Health Services	Diabetes Monitoring for People with Schizophrenia or Bipolar Disorder Using Antipsychotic Medications	Y	Y	HEDIS
1	A	Preventive Health Services	Diabetes Monitoring for People with Diabetes and Schizophrenia	Y	Y	HEDIS
1	A	Preventive Health Services	Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia	Y	Y	HEDIS
1	A	Mental Health Follow-Up After Discharge	Follow-Up After Hospitalization for Mental Illness	Y	Y	HEDIS
1	A	Mental Health Utilization	Mental Health Utilization	Y	Y	HEDIS
1	A	Substance Use Identification	Identification of Alcohol and Other Drug Services	Y	Y	HEDIS
1	A	Substance Use Initiation/Engagement	Initiation and Engagement of Alcohol and Other Drug Dependence Treatment	Y	Y	HEDIS
1	A	Rehospitalization	All Cause Readmission	Y	Y	HEDIS

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QARR Metrics on Use of Services & Physical Health

Start Year	Method (A=Administrative)	Domain	Measure Name	MCO	HARP	Specifications to Use
1	A	ED Use	Ambulatory Care	Y	Y	HEDIS
1	A	Hospital Services	Inpatient Utilization (General Hospital-Acute Care)	Y	Y	HEDIS
1	A	Adult Access to Preventive/Ambulatory Health Services	Adult Access to Preventive/Ambulatory Health Services	Y	Y	HEDIS
1	A	Care for Chronic Conditions	Use of Appropriate Medications for People with Asthma	Y	Y	HEDIS
1	A	Care for Chronic Conditions	Medication Management for People with Asthma	Y	Y	HEDIS
1	H	Care for Chronic Conditions	Comprehensive Diabetes Care	Y	Y	HEDIS
1	H	Care for Chronic Conditions	Cholesterol Management for Patients with Cardiovascular Conditions	Y	Y	HEDIS
1	A	Care for Chronic Conditions	Persistence of Beta-Blocker Treatment After a Heart Attack	Y	Y	HEDIS
1	A	HIV/AIDS	HIV/AIDS Comprehensive Care	Y	Y	NYS QARR
1	A	Preventive Health Services	Chlamydia Screening in Women	Y	Y	HEDIS
1	H	Preventive Health Services	Colorectal Cancer Screening	Y	Y	HEDIS
1	H	Preventive Health Services	Adult BMI Assessment	Y	Y	HEDIS
1	H	Preventive Health Services	Controlling High Blood Pressure	Y	Y	HEDIS
1	A	Provider Network	Board Certification	Y	Y	HEDIS
1	S	Smoking Cessation	Medical Assistance with Smoking Cessation	Y	Y	CAHPS

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QARR Metrics Related to Satisfaction

Start Year	Method (A=Administrative)	Domain	Measure Name	MCO	HARP	Specifications to Use
1	S	Satisfaction with Care	Satisfaction with Access to Care - Getting Care Needed	Y	Y	CAHPS
1	S	Satisfaction with Care	Satisfaction with Access to Care - Getting Care Quickly	Y	Y	CAHPS
1	S	Satisfaction with Care	Satisfaction with Health Plan - Customer Service	Y	Y	CAHPS
1	S	Satisfaction with Care	Satisfaction with Experience of Care - Care Coordination	Y	Y	CAHPS
1	S	Satisfaction with Care	Satisfaction with Experience of Care - Wellness Discussion	Y	Y	CAHPS
1	S	Satisfaction with Care	Satisfaction with Experience of Care - Rating of Overall Healthcare	Y	Y	CAHPS
1	S	Satisfaction with Care	Satisfaction with Experience of Care - Getting Needed Counseling or Treatment	Y	Y	CAHPS
1	S	Satisfaction with Care	Satisfaction with Experience of Care - Rating of Counseling or Treatment	Y	Y	CAHPS
1	S	Satisfaction with Care	Satisfaction with Experience of Care - Collaborative Decision Making	Y	Y	CAHPS

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New, First Year in QARR Reported in Aggregate Only, Plan-to-Plan Comparison Starts in Second Year

Start Year	Method (A=Administrative)	Domain	Measure Name	MCO	HARP	Specifications to Use
1+	A	Behavioral Health Readmission	Behavioral Health Readmission to Same Level of Care	Y	Y	TBD
1+	A	Mental Health Follow-Up After Discharge	Follow Up After Hospitalization for Mental Illness with Retention	Y	Y	TBD
1+	A	SUD Specific Metrics	TBD	Y	Y	TBD