DRAFT

MEDICAID REDESIGN TEAM, MANAGED CARE, AND BEHAVIORAL HEALTH

  • Draft is also available in Portable Document Format (PDF, 171KB)

BEHAVIORAL HEALTH ORGANIZATIONS AND INTEGRATED FULL BENEFIT SPECIAL NEEDS PLANS

MRT meeting of the Behavioral Health Subcommittee October 18, 2012

Behavioral Health Subcommittee Recommendations

  • Today´s presentation focuses on some of the overarching recommendations of the subcommittee´s final report:
    • Managed care approaches using risk-bearing SNPs and/or BHOs should be developed. In NYC, full-benefit SNPs should be developed to include mental health, physical health, and substance abuse populations.
    • SNPs/BHOs should be given responsibilities to pay for inpatient care at State psychiatric hospitals and to coordinate discharge planning. This will help reduce incentive for BHOs/SNPs to institutionalize people in State psychiatric hospitals. It is expected that facility downsizing would occur on a phased basis.
    • Advance the core principle that manage care approaches for people with behavioral health care needs should assist enrollees in recovery and in functioning in meaningful life roles.
    • Use an 1115 waiver to advance the recommendations outlined in the MRT BH workgroup final recommendations report.
  • As program design work continues, the following BH subcommittee report topics will serve as a guide:
    • Financing and Payment
    • Contracting with Behavioral Health Plans and Benefit Package Design
    • Eligibility for SNP/BHO Enrollment
    • Promotion of Improved BH care in primary care
    • Health Information Technology and Information Exchange
    • Performance Metrics/Evaluation
    • Children, Youth and Families
    • Peer Services and Engagement
    • Services for the Uninsured
    • Health Homes

The Current Medicaid Managed Care Environment and Enrollment Provides the Framework

  • SSI Population
    • Managed Care - Physical Health Benefit
    • Fee-For-Service - Behavioral Health
  • Non-SSI Population
    • Managed Care - Physical Health Benefit / Limited
    • Behavioral Health (Inpatient and Clinic)
    • Fee-For-Service - Specialty Behavioral Health
  • Under reform, an individual´s meaningful health care provider relationships should be preserved whenever possible
  • Build from existing 1115 Partnership Plan

Behavioral Health and Agency Draft Agreements

  • The implementation path: NYS will use existing authorities in state statute and CMS approvals for specialty management
    • Integrated Full Benefit Special Needs Plans (especially in NYC) and Behavioral Health Organizations working with or possibly within mainstream plans

Managed Care Models - Options

  • Several models are under discussion both within the NYC region and the rest of the State. The goal of all is to meet the continuum of specialized needs of persons receiving behavioral health services.
  • Model options under discussion include:
    • Outside of NYC, Mainstream Plan enrollment with either a BHO or other contracted arrangement delivering managed BH services to the Plan enrollee.
    • In NYC, full-benefit integrated SNPs (affiliated with existing plan or freestanding) for high need populations and alternative arrangement for non-SNP enrollees.

Requirements of an Integrated, Full Benefit Special Needs Plan

  • FBSNPs:
    • In NYC (and other areas of the State where viable) full benefit integrated Special Needs Plans (FB-SNPs) are the preferred managed care vehicle for members with significant Behavioral Health conditions.
    • FBSNP eligibility criteria and specialized benefits will be developed by DOH, OASAS, OMH and NYC with stakeholder input.
    • FBSNPs will be expected to be fully integrated plans that will manage the entire Medicaid benefit for patients including: physical health, behavioral health, acute care, long term care, and pharmacy.
    • FBSNPs must be able to create an integrated network with an ability to share information among network providers and provide intensive care coordination services, as well as effectively communicate with non-network providers when necessary.
    • FBSNPs must be licensed risk bearing entities in NYS.
    • A limited number of FBSNPs will be selected and preference given to existing plans with robust specialty behavioral health investment including active partnerships with HHs.
    • New entrant, "free-standing" FBSNPs will be considered.
    • FBSNPs will be required to contract with Health Homes.
    • Existing plans that are designated as FBSNPs must demonstrate intent to reach out to all FBSNP eligible enrollees, counsel them on the advantages of enrollment, and enroll them in a FBSNP unless the member declines.
    • People assigned to the FBSNP from the mainstream plan will be able to access the Plan´s primary care network and continue with the same primary care provider they had as a mainstream plan enrollee.

Strategies to Maximize FBSNP Enrollment in NYC

  • Specialized enrollment strategies will be considered to maximize the enrollment of the higher need eligible population into FBSNPs, including:
    • Encouraging plans with large numbers of eligible members to develop a FBSNP as the preferred plan for their high-need Behavioral Health members;
    • FBSNP capitation rates should reflect the high needs of the eligible population, the additional responsibilities related to care management, greater administrative costs and enhanced benefit package for this special needs population;
    • Reinvestment of savings;
    • The development from savings of a member specific self-directed spending account available only through FBSNPs to purchase needed services or materials which will facilitate recovery outcomes.

Draft Behavioral Health Organizations

  • Mainstream Plans/BHOs
    • Mainstream plans will be responsible for all behavioral health services for all their members, which includes existing services and those carved out of mainstream managed care contracts.
    • Plans will be required to either contract with a state certified BHO OR demonstrate capacity to meet carefully constructed State requirements for management of behavioral health benefits.
    • Plan requirements will be jointly developed and monitored by OMH, OASAS and DOH with significant stakeholder input.
    • This may be the predominant model in most areas outside of NYC.

Additional Aspects of Design

  • With appropriate CMS approvals, plans will be given responsibility to pay for inpatient care at State psychiatric hospitals and coordinate discharge planning. As State PCs are freed up through downsizing and admission diversion, these funds will be reinvested to fund community-based support services.
  • The State will pursue CMS approval of "in lieu of" service flexibility, including for OASAS and OMH community-based and State operated inpatient rehabilitation services.
  • Coordination of Medicaid capitated services and non-Medicaid services funded outside of capitation:
    • Housing
    • Clubhouses
    • Peer operated services
    • Others to be considered

Raising Standards for Behavioral Health Care

  • Raise the bar on requirements:
    • Expertise and experience, network, access, service utilization/penetration, care coordination
    • Quality Measures "beyond HEDIS"
    • Engaging the disengaged
    • Promoting consumer engagement throughout
    • Assuring reinvestment of savings in services and supports for people with BH needs
  • Ongoing monitoring by the entire BH community

BH Benefit Design-Next Steps

  • Ongoing stakeholder input is received through the MRT process and through the BH workgroup.
  • Design work has begun in coordination between OMH, OASAS, DOH, and NYC.
  • Mercer was engaged as a design and actuarial consultant.
  • Periodic opportunities for input from various stakeholders to solicit input will continue through the planning process.

Draft BH Benefit Redesign

  • BHO/SNP Draft Implementation Timeline
Date Task
Spring 2013 Finalize BHO/FBSNP program design
Summer 2013 Finalize BHO/FBSNP managed care contract requirements and financing

Publish procurement documents for minimum 30 days
Fall/Winter 2013 Select FBSNPs/BHOs
Spring 2014 Fully operational

MEDICAID REDESIGN TEAM

ROADMAP FOR EARLY IDENTIFICATION, SERVICE EXCELLENCE, AND CARE MANAGEMENT FOR CHILDREN WITH SPECIAL NEEDS:

BEHAVIORAL HEALTH AND FOSTER CARE

MRT meeting of the Behavioral Health Subcommittee
October 18, 2012

Mainstream Plan Primary Care Benefits and Accountability Measures

  • Investments in primary care to improve the identification of children and families with trauma, emotional disturbances, substance use and parenting concerns are essential.
  • Collaborative care offers basic levels of assessment and diagnosis, behavioral crisis intervention, psychotropic medication management, and support and education for families with primary care.
  • Use of these targeted and proven early interventions are rooted in the Triple Aim and are highly effective and less costly and key to helping families to raise resilient children.
  • Moving from policy vision to reality, implementation activities will need to be phased in; this approach will include incentives, expand outcome measures (within QARR) and offer training.
  • Enhanced benefits (supported by new funding) should include:
    • Screening, assessment, and management in primary care (collaborative care models)
      • Primary care physician management of low level behavioral health needs, including psychopharmacological management
      • Includes care coordination and low intensity wraparound services such as family support and crisis support
    • Perinatal depression screening and management

Access to Behavioral Health Specialty Care across ALL Insurers

  • The Essential Health Benefit developed for New York´s Health Insurance Exchange(s) must include a robust benefit for collaborative care in primary care and for specialty behavioral health treatment and care coordination.
  • Adequate payment for behavioral health services will need to be ensured across payers.
  • Strategic use of "deeming" children as a family of one for the Medicaid eligibility based upon serious emotional disturbance and risk of hospitalization or residential placement that cannot access sufficient services via their health plan.

All Medicaid Enrolled Children
(Age: 0-20 yrs)

Children´s Specialty Medicaid Managed Care: DRAFT September 2012