Harm Reduction Services

May 2018

Overview

Effective July 1, 2018, harm reduction services (HRS) will be available to eligible recipients in Medicaid managed care (MMC) and fee–for–service (FFS) Medicaid. Currently, harm reduction services are grant– funded by the New York State Department of Health (NYSDOH) AIDS Institute and provided by NYSDOH–authorized and waivered syringe exchange programs (SEPs).

As of the effective date, harm reduction services that are covered by Medicaid may only be provided by NYSDOH–authorized and waivered SEPs which are enrolled as Medicaid providers. Certain harm reduction services, such as syringe exchange, will remain grant–funded by the NYSDOH AIDS Institute and continue to be provided by these SEPs.

MMC plans will be required to cover harm reduction services that have been recommended in writing by a physician or other licensed practitioner1 for MMC enrollees and to reimburse harm reduction services organizations for providing these services to plan enrollees. This change applies to all MMC plans, including mainstream MMC plans, HIV Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs).

Except as noted in Section VI, MMC plans are required to offer contracts to each SEP prepared to bill Medicaid in their service area for a two–year transition period ending on June 30, 2020. The State will notify plans as additional harm reduction service providers phase into Medicaid billing readiness over this transition period. Reimbursement will be provided in accordance with Medicaid FFS rates for two years from program inception.

The following guidelines identify the scope of coverage, continuity of care, MMC plan and provider responsibilities, data and rate adjustment, network requirements, and billing and payment.

INDEX

  1. Scope of coverage
  2. Continuity of care/transitional care
  3. Responsibilities of Medicaid managed care plans
  4. Responsibilities of harm reduction services providers
  5. Utilization data and MMC plan rate adjustment
  6. Network requirements
  7. Billing and payment
  8. Right to appeal

I. Scope of coverage

  1. Harm reduction services represent a fully integrated client–oriented approach to health and wellness, which includes, but is not limited to, overdose prevention and response and preventing transmission of HIV, Hepatitis B and C, and other illnesses in substance users. New York State Department of Health (Department) approved harm reduction programs, as defined below, provide these services in accordance with an assessment and an individualized plan of care. Harm reduction services are a medical service under the Benefit Package.
  2. MMC plans will be responsible for covering harm reduction services as set forth in the approved State Plan Amendment, for their enrollees:
    1. Development of a Plan of Care through either an initial assessment or a scheduled or event–generated reassessment. A reassessment is a scheduled or event– generated formal re–examination of the client´s situation, functioning, substance use, and medical and psychosocial needs to identify changes which have occurred since the initial or most recent assessment. The reassessment measures progress towards the desired goals and is used to prepare a new or revised harm reduction program plan or confirm that current services remain appropriate. Referrals may be made for behavioral health interventions, support groups, wellness services, substance use disorder (SUD) treatment, and overdose prevention as needed.
    2. Individual and Group Supportive Counseling are part of a package of remedial services recommended by a physician or other licensed practitioner and are for maximum restoration of an enrollee to his or her best possible functional level. Effective supportive counseling assists individuals in understanding how to reduce the behaviors that interfere with their ability to lead healthy, safe lives and to restore them to their best possible functional level. Supportive counseling may be provided to an individual or in a group setting and can cover such topics as HIV/HCV/STD status or substance use disclosure to family members and friends; addressing stigma for drug users in accessing services; maximizing health care services interactions; reducing substance use or using more safely and avoiding overdose; and addressing anxiety, anger, and depressive episodes.
    3. Medication Management and Treatment Adherence Counseling assist clients to recognize the need for medication to address substance use or psychiatric issues, reinforce the importance of adherence to treatment regimens, and identify tools to follow the prescribed regimens. Such services are remedial services recommended by a physician or other licensed practitioner and are for maximum restoration of an enrollee to his or her best possible functional level.
    4. Psychoeducation – Support Groups are stand–alone services that may also be used to supplement individual and/or group supportive counseling. Such services are remedial services recommended by a physician or other licensed practitioner. Support groups restore individuals to his or her best possible functional level by focusing on group members´ issues and experiences relative to substance use, finances, medical/health care, support system, incarceration history and other factors that contribute to risk behaviors for HIV/HCV/STD. Support groups may be facilitated by a direct service provider, a case worker, or the director of harm reduction services or co–facilitated by a peer.
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II. Continuity of care/transitional care

  1. As of the effective date, two types of funding exist for harm reduction services–Medicaid and grant funds. Most clients enrolling in Medicaid funded harm reduction services are also receiving grant–funded harm reduction services, such as syringe exchange, acupressure, overdose training, etc.
  2. Current managed care plan enrollees receiving grant–funded harm reduction services are permitted to keep their current provider of harm reduction services. In addition, clients may utilize services at more than one harm reduction organization in a provider network. Each harm reduction organization will keep an up–to–date plan of care for the client.
  3. Clients may enter harm reduction services via referral from sources such as the SEPs where harm reduction services take place, a health care provider, a managed care plan, a health home, or a substance use disorder treatment program. Such services must be recommended in writing by a physician or other licensed practitioner internal or external to the Syringe Exchange Program (SEP) where services are provided. Upon request, the MMC plan must coordinate appropriate referrals for the enrollee to attend a participating harm reduction services organization for initial assessment and development of a plan of care.
  4. Disenrollment from Medicaid–funded harm reduction services: regardless of the reason for disenrollment, upon notice of or request for disenrollment, the harm reduction organization must prepare a written discharge plan whenever possible for an enrollee for whom a plan of care has been established to assure continuity of care at the time of disenrollment.
    1. A discharge plan should be provided by the harm reduction organization to the enrollee, and with the enrollee´s consent, to his/her legal guardian where applicable and to his/her designated care provider within fifteen (15) days of the notice of or request for disenrollment.
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III. Responsibilities of Medicaid managed care plans

  1. MMC plans are responsible for notifying current enrollees of the harm reduction benefit at least 30 days in advance of the effective date.
  2. Plans must monitor that services are provided pursuant to an individualized plan of care by NYSDOH–authorized waivered SEPs serving as harm reduction organizations providing Medicaid services.
  3. Harm reduction is considered a medical service for purposes of the benefit package, contracting, and claims processing. To ensure the availability of services and continuity of care for enrollees receiving harm reduction services, MMC plans must contract with harm reduction organizations, which are NYSDOH–authorized waivered SEPs and which are enrolled in the Medicaid program and/or enter into single–case agreements only with such providers that allow enrollees to access the necessary services only from such providers on an out–of–network basis.
  4. Department–authorized waivered SEPs are the only organizations eligible to provide harm reduction services to Medicaid managed care enrollees and under Fee–for–Service. The state provided a list of SEPs to MMC plans on October 30, 2017.
  5. MMC plans will reimburse harm reduction services organizations for recommended harm reduction services provided to plan enrollees, pursuant to an individualized plan of care. Harm reduction services outlined in the Scope of Coverage section of this document are reimbursable. Syringe exchange is not a covered Medicaid–covered service.
  6. MMC plans may not require prior authorization for harm reduction services.
  7. For the first six months commencing July 1, 2018, MMC plans may not deny harm reduction services provided pursuant to an individualized plan of care based on utilization review/medical necessity criteria. Thereafter, MMC plans may conduct concurrent review and retrospective review for medical necessity in accordance with federal regulation, NYS Public Health Law and the Medicaid Managed Care/HIV Special Needs Plan/Health and Recovery Plan Model Contract (Mode Contract). MMC plans will submit their criteria for authorization and utilization management of HRS to the Department for approval prior to use. MMC plans may coordinate with the harm reduction service provider to avoid unnecessary duplication of services received under the harm reduction individualized plan of care with other services the enrollee may be receiving.
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IV. Responsibilities of harm reduction services providers

All harm reduction service providers must follow the MMC plan provider contract and/or provider manual and billing requirements.

  1. For existing clients, the harm reduction services provider must notify the client´s MMC plan as soon as possible that the plan´s enrollee has signed consent forms and is receiving services.
  2. For new clients, the harm reduction services provider must:
    1. Check the client´s MMC plan eligibility prior to performing the assessment or admitting the client into the program;
    2. Notify the MMC plan that the enrollee has presented a recommendation for services from a physician or other licensed practitioner and, if the harm reduction services provider is outside the MMC plan´s geographic area, have the MMC plan arrange for the enrollee to be seen by the out of network provider.
    3. Commence services the same day the client presents for services if proper consent forms are signed and the client is seeking immediate assistance.
  3. An enrollee´s plan of care for harm reduction services may be changed every six (6) months or due to an event–driven reassessment.
    1. A new recommendation by a physician or other licensed practitioner is not required to continue harm reduction services.
    2. Reassessments are conducted by the harm reduction services organization. The harm reduction services organization must notify the MMC plan if it is recommending the member be discharged from the program.
    3. Harm reduction services can be utilized concurrently with substance treatment services provided by a behavioral health organization.
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V. Utilization data and MMC plan rate adjustment

Adjustments will be made to the medical components of the 2018 MMC plan premiums to accommodate the addition of this new benefit. MMC plans will be notified of any applicable changes to the MMC Operating Report (MMCOR).

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VI. Network requirements

  1. DOH has provided harm reduction services organizations with a list of MMC plans that these organizations may contract with to provide harm reduction services.
  2. For the period of two years beginning July 1, 2018, a MMC plan must offer contracts with all Department–authorized harm reduction services organizations enrolled as Medicaid providers and operating in the counties in which the plan´s enrollees reside.
  3. Outside of the Plan´s service area, MMC plans must permit enrollees to access services through out–of–network arrangements, though such arrangements must be only with Department–authorized harm reduction services organizations.
  4. A managed care plan may enter into single–case agreements with harm reduction service organizations providing services to fewer than five enrollees of the plan or to arrange for enrollee access outside the plan´s service area.
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VII. Billing and payment

  1. The addition of harm reduction services will include adjustment to MMC plan premium rates by the State to reflect projected expenditures of harm reduction services for plan enrollees.
  2. For a period of two years beginning July 1, 2018, MMC plans will pay Medicaid fee–for– service (FFS) harm reduction services rates for their new and existing enrollees receiving these services. Following this two–year period, MMC plans and providers may negotiate contracts with payment terms that may be different than those FFS rates.
  3. After this two–year period commencing July 1, 2018, should the harm reduction services organization not agree to the Medicaid FFS–equivalent rate(s), the MMC plan may facilitate the enrollee´s enrollment in or transfer to another provider. The MMC plan must ensure there is no gap in service provision and all other continuity of and access to care requirements in this policy and the Model Contract are followed.
  4. Plans will accept claims for HRS submitted in accordance with FFS billing guidance.
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VIII. Right to appeal

After the six–month period commencing July 1, 2018, the MMC plan may develop written clinical criteria guidelines for utilization review of harm reduction services, and conduct concurrent and retrospective review in accordance with federal regulation, NYS Public Health Law and the Model Contract, including timely notification of adverse benefit determinations, and provision of applicable enrollee appeal and fair hearing rights. MMC plans will submit their criteria for authorization and utilization management of HRS to the Department for approval prior to use.

With written consent of the enrollee, the provider may file appeals of adverse benefit determinations with the plan on behalf of the enrollee.

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1. Such as a nurse practitioner; physician; physician assistant; psychiatric nurse practitioner; psychiatrist; psychologist: registered professional nurse; licensed mental health professional; licensed clinical social worker (LCSW); and licensed master social worker (LMSW) if supervised by an LCSW, licensed psychologist, or psychiatrist employed by the agency. Note: the recommending provider can include in–house staff.1