Behavioral Health Medicaid Managed Care Kick-Off Forums

Redesign Medicaid in New York State

Presented by: Gary Weiskopf, Associate Commissioner for Managed Care,

NYS Office of Mental Health

Donna Bradbury, Associate Commissioner for Integrated Community Services for Children and Families, NYS Office of Mental Health

Linda Kelly, Project Director, Behavioral Health Transition, NYS Department of Health

Pat Lincourt, MSW, Director, Clinical Services Unit, OASAS

Ilyana Meltzer, MPP, Addictions Planning Analyst, Division of Practice Innovation and Care Management, OASAS

2

Agenda

Welcome

NYS General Managed Care – Overview of key features

NYS Behavioral Health (BH) Transition Medicaid Managed Care

Introduction to Managed Care Technical Assistance Center (MCTAC)

Phased Approach to Technical Assistance

Discussion of Critical Factors for Managed Care Readiness

Available Resources and Training Opportunities

Plan/Provider Networking Opportunities

3

Medicaid Managed Care: An Overview

Redesign Medicaid in New York State

September 2014

Introduction

Where are we today?

What does the Medicaid Managed Care Program look like right now?

Who must enroll in a Medicaid Managed Care Plan?

What do providers need to know about working with Medicaid Managed Care Plans?

Where are we going?

5

What is Managed Care?

Managed Care is a general term used to describe any health insurance plan or system that coordinates care through a primary care practitioner or is otherwise structured to control quality, cost and utilization, focusing on preventive care.

Principles of managed care can be found in many health insurance products from indemnity plans, PPOs, EPOs, to ERISA and Self Insured plans.

Authorization

Capitation

Referral

Preferred networks

6

Medicaid Managed Care

A NYS-sponsored health insurance program for adults and children who have little or no income or who receive Supplemental Security Income (SSI) Authorized under Section 364-j of Social Services Law

NYS contracts with Managed Care Organizations who then pay the participating provider directly for services

NYS pays the plans a capitated rate (per member/per month)

Benefits consist of plan covered services and Medicaid FFS carve-out services

Most carve-out services will be covered by MMC by 2015

4,038,921 Medicaid recipients enrolled statewide as of July 2014

7 7

Medicaid Managed Care Plans

NYS Mainstream Medicaid Managed Care Plans (MMCP)

Are HMOs, PHSPs, or HIV SNPs

Certified under Article 44 of the Public Health Law

By the NYS Department of Health in conjunction with the NYS Department of Financial Services

Qualified by NYS Department of Health to provide Medicaid services

Meet federal regulations at 42 CFR 438

These plans are responsible for assuring enrollees have access to a comprehensive range of preventative, primary, specialty, ancillary and inpatient services through their provider network

8

Basics of Coverage

MMC enrollees are entitled to all Medicaid covered benefits

FFS coverage is the minimum level of service that plans must provide

Plans may establish their own: Prior approval policies

Reimbursement levels/methodologies

Medical necessity (utilization review) criteria

9

What Is Covered Under Medicaid Managed Care?

Inpatient Hospital Services

Emergency Services

Physician/Nurse Practitioner/Midwifery Services

Preventive Health Services

Laboratory Services

Radiology Services

Prescription/Non Prescription Drugs and Medical Supplies

Home Health Services

10

What Is Covered Under Medicaid Managed Care?

Mental Health/Substance Use Disorder

Dental

Orthodontia

Rehabilitation Services

Durable Medical Equipment (DME)

Vision Care

Personal Care Services

Consumer Directed Personal Assistance

Hospice Services

Family Planning (Fidelis does not cover; services are available through FFS Medicaid)

11

Current Mental Health (MH) & Substance Use Disorder

(SUD) Services Inpatient MH Services

Covered; including voluntary and involuntary admission

MMC SSI related Enrollees access through Medicaid FFS

Outpatient MH Services

Covered; MMCP must make available in an accessible manner all services required by OMH regulations found at 14 NYCRR 599

MMC SSI related Enrollees access through Medicaid FFS

Inpatient SUD Services

Covered pursuant to OASAS regulations found at 14 NYCRR 818

Outpatient SUD Services

MMC Enrollees access outpatient chemical dependency services and Opioid clinics through Medicaid FFS

12

Behavioral Health

Behavioral Health Managed Care Vision:

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

Integration of all Medicaid Behavioral Health (BH) and Physical Health (PH) benefits under managed care

13

Enrollment into a Plan Enrollment into a Medicaid Managed Care Plan is mandatory

unless the individual is exempt or excluded

14

MMC Application Avenues

New York State of Health, The Official Health Plan Marketplace or by phone at (855) 355-5777

Medicaid Managed Care Plan

Navigators and Certified Application Specialists

Medicaid Helpline (800)541-2831

Local District Social Services Offices

15

Medicaid Managed Care Education Process

Enrollee Education: Primarily the responsibility of the LDSS; NYS enrollment broker,

New York Medicaid CHOICE; or Application Counselor

May be in person, over the phone, via internet or by mailings

Education Includes: Choice of plans and services offered

Provider information

How to change plans and/or providers

Consumer rights

16

Exemptions

Most Medicaid eligible individuals are required to enroll in a MMCP unless exempt or excluded

An exemption means that a consumer is not required to join a MMCP unless he or she so chooses If a consumer is already enrolled in a MMCP and applies for and receives an exemption, he

or she will be disenrolled from the MMCP

Exempt individuals can choose to enroll in a plan or remain in FFS Medicaid: Person with chronic medical conditions with a non-participating physician – limited to a

single 6 month exemption

Residents of long term substance use disorder treatment programs

Developmentally Disabled and other waivered individuals

Native Americans

17

18

How to Obtain an Exemption

Many exempt and excluded individuals are system identifiable, and the consumer does not need to apply for an exemption (Waiver Programs and Developmentally Disabled individuals)

There are a some exemptions when application is necessary: Six month chronic medical Long term residential Residents of Intermediate Care Facilities Native Americans must verify their status with official documentation

18

Who Is Excluded From MMC?

Medicaid/Medicare dually eligible individuals

Persons with comprehensive Third Party Health Insurance (TPHI)

Individuals who will be eligible for Medicaid only after spending some of their own money for medical needs (spend-down cases)

Individuals residing in nursing homes or hospice programs at the time Medicaid application is submitted

Individuals eligible for TB services only

19 19

20

When Does Coverage Begin?

Medicaid Managed Care: Medicaid eligibility is established first

MMC enrollment is processed prospectively

Eligibility begins in the month of application, and may include the three prior months in some cases

Medicaid eligible individuals are covered by FFS Medicaid until the plan enrollment is effectuated

20

21

When Does Coverage Begin ?

Example: Medicaid application submitted 5/12/2014

If eligible, the consumer receives FFS Medicaid coverage beginning 5/1/2014

Consumer selects a plan on 6/12/2014

Effective date of enrollment in a MMC health plan is 7/1/2014

21

Working with Medicaid Managed Care Plans

Consumer Rights

Provider Rights

Authorizations and Appeals

22 22

23

NYS Medicaid Managed Care Consumer Rights

Right to complain, grieve and appeal

Notification of denials of treatment and grievance outcomes

Clinical rationale for the denial

Appeal of denials & timeframes for responding

If appeal timeframes not met, the denial is reversed

External appeal

For MMC

Expanded transitional care

Right to appeal any plan Action

Right to Fair Hearing and Aid Continuing

Reasonable assistance filing complaints and appeals

Right to information about plans

Benefit description

Referral and authorization requirements

Provider network

Access to needed care

Right to out of network care

Prudent layperson emergency care

Transitional care

Access to specialty care & specialty care centers

NYS Provider Rights

Statute and Current MMC requirements: Patient/Provider relationship Contract Requirements Network Requirements Payment Rules Authorizations and Appeals

24

Patient/Provider Relationship

Provider may discuss all treatment options with member, even if service not be covered by plan.

Provider may assist the enrollee with a grievance, appeal or external appeal.

No penalty or retaliation if provider files complaint with government entity.

Provider contract may not be terminated solely because provider advocated for enrollee; filed complaint; appealed plan decision; or asked for hearing.

25

Provider Contracting

Provider Contract Guidelines

plan submits contracts to NYSDOH for approval

http://www.health.ny.gov/health_care/managed_care/hmoipa/hmo_ipa.htm

Applies to IPA arrangements

NYSDOH reviews risk sharing arrangements; HMO must retain some risk.

Contract must provide the payment methodology; manner and timing of adjustments; and process for disputing and correcting errors.

Hearing process if health plan seeks to terminate contract (except if immediate patient harm).

90 day notice and opt out for plan initiated adverse change in contract reimbursement (unless otherwise agreed to in contract).

26

Network Requirements

Upon request, plans must provide: Written application procedures the criteria & minimum qualifications provider must meet to be credentialed

Credentialing qualifications must be developed with input from qualified health professionals

Completed network application must be reviewed in 90 days applicant notified whether s/he is credentialed or whether additional time is needed

because there is a lack of necessary documentation from a third party Performance Reviews

Plan must inform providers of information the plan has to evaluate the performance of the provider

Plan must consult providers in the development of profiling methodologies and analysis Profiling data must be measured against standard criteria and that of a similar group of

providers with a comparable patient population Providers must be given opportunity to discuss unique nature of their patient population

27

Prompt Pay Law

30 day processing of clean electronic claims

Written notice of reason for denied claims

Insurer pays interest for late payments

At least 90 days to file claims (MMC non-pars have 15 months)

Untimely filing dispute resolution process

Coding dispute resolution process (art 28 hospitals only)

Payment Rules

30 day written notice before recoupment

Non-par inpatient and ER paid at FFS rate

Prescriber prevails for some drug classes

Transitional care coverage for new enrollees

Alternate level of care

28

MMC Service Authorizations

No authorization required for ER

Plan authorization determinations as per Appendix F of the Model Contract

Notification requirements

Includes both benefit determinations and medical necessity reviews

Clinical decisions made by health professionals

Based on written clinical criteria

Once authorized, authorization may not be changed without receipt of new information, fraud or loss of coverage

29

MMC Service Authorizations

New, review and notice in Expedited, 3 bd from request

Standard, 3 bd from all info and no more than 14 days from request

Concurrent, review and notice in Expedited, 1 bd from all info and no more than 3 business days from request

Standard, 1 bd from all info and no more than 14 days from request

Home health care following inpatient admission on Friday or day before holiday, 72 hours after all info, no more than 3 bd of request

All may be extended up to 14 days if: plan needs more info and in member’s best interest to extend

Enrollee or provider requests extension

Verbal and written notice made to enrollee and provider 30

Disagreements with Care Plan/ Adverse

Determinations Plan may issue adverse determinations – Notice of Action

Plan clinical rationale must demonstrate Review of enrollee specific data

Specific criteria not met

Be sufficient to enable judgment for basis of appeal

Enrollee right to appeal, external appeal and fair hearing described in notice – all may be expedited

Providers have appeal rights on own behalf

31

Disagreements with Care Plan/

Adverse Determinations Possible next steps:

Discuss alternate service options with MMCP care manager o MMCPs must arrange for services to meet care needs

Request specific clinical review criteria used

File appeal with MMCP; include documented support for requested service

File external appeal or fair hearing

Contact NYS Department of Health for issues with process, access to or quality of care

32

Plan Action Appeals

Enrollees have at least 60 business days to file

Plan determines in:

Expedited, 2 bd of all info and no more than 3 bd from appeal

Standard, no later than 30 days from appeal

All may be extended up to 14 days if:

plan needs more info and in member’s best interest to extend

Enrollee or provider requests extension

Notice to enrollee and provider:

Expedited verbal notice at time of decision, written in 24 hours

Standard written notice within 2 business days of decision

33

Appeal conducted by clinical reviewer that doesn’t work for the plan or State

When plan denies service as: not medically necessary; experimental/investigational; or Out of network and not materially different from a service available from a network provider

Enrollees have 4 months to file external appeal after receiving the plan’s response to a first level appeal (final adverse determination) Plan and enrollee may jointly agree to waive internal process, file EA within 4 months of this

agreement If filing expedited plan appeal, enrollee may file expedited external appeal at the same time If plan does not follow appeal process correctly, enrollee may directly file external appeal

Providers have independent right to external appeal concurrent and retrospective reviews 60 days to file

External Appeal

34 34

Department of Health Complaints

Enrollees and providers may file a complaint regarding managed care plans to DOH

1-800-206-8125

managedcarecomplaint@health.ny.gov

When filing:

Identify plan and enrollee

Provide all documents from/to plan

Medical record not necessary

Issues not within DOH jurisdiction may be referred

DOH is unable to arbitrate or resolve contractual disputes in the absence of a specific governing law

File prompt pay complaints with Department of Financial Services

35

Provider Responsibilities

Verify Medicaid managed care eligibility prior to assessment or admission.

Know provider contract and plan policies and procedures.

Obtain initial authorization, as required, from the plan and provide services according to the approved care plan for the duration of the authorization.

Plans are part of the patient-centered planning team. Submit full information with request to support treatment level proposed in care plan as per plan procedures.

36

Resources 1. Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan Model Contract

a) Section 10: Benefit Package Requirements

b) Appendix F: Action and Grievance System Requirements

c) Appendix K: Prepaid Benefit Package Definitions of Covered and Non-Covered Services

2. New York State Department of Health http://www.health.ny.gov/

3. New York State Department of Financial Services http://www.dfs.ny.gov/

a) Provider rights: http://www.dfs.ny.gov/insurance/hprovrght.htm

b) Prompt Pay Law: http://www.dfs.ny.gov/insurance/provlhow.htm

4. The Centers for Medicare and Medicaid Services http://cms.hhs.gov/

5. Behavioral Health Transition http://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health_transition.htm

6. Medicaid Redesign Team http://www.health.ny.gov/health_care/medicaid/redesign/?utm_source=doh&utm_medium=hp-button&utm_campaign=mrt

37

Implementing Medicaid Behavioral Health Reform

Redesign Medicaid in New York State

Transitioning Behavioral Health (BH) Services into Managed

Care

Important Features to Successfully

Integrate BH Services into Managed Care

Medicaid Redesign Team (MRT): Objectives

Redesigning New York's Medicaid Program – home page http://www.health.ny.gov/health_care/medicaid/redesign/

Fundamental restructuring of the Medicaid program to achieve:

Measurable improvement in health outcomes

Sustainable cost control

More efficient administrative structure

Support better integration of care

40

Principles of BH Benefit Design and Services Management

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

Behavioral Health Transition to Managed Care Home Page http://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health_transition.htm

41

Findings from BHO Phase 1

42

BHO Phase I post-discharge outcomes for Adult Mental Health discharges, CY 2012

Medicaid claims data

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

30-day readmission rate Outpatient MH or SUD treatmentwithin 7 days of discharge

Two or more MH outpatient visitswithin 30 days of discharge

NYC

Rest of state

BHO Phase I post-discharge outcomes for SUD discharges, CY 2012

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

45-day readmission rate Lower level of SUD service or MHoutpatient care within 14 days of

discharge

Three or more SUD lower levelservices within 30 days of discharge

NYC

Rest of state

Medicaid claims data

No physical health condition identified: 64%

Physical health condition identified: 36%

No physical health appointment made: 82%

Physical health appointment made: 18%

Integrated Care: In BHO Phase I, how often did behavioral health inpatient providers identify general medical conditions requiring

follow-up, and did they arrange aftercare appointments?

Data submitted by BHO

Based upon 56,167 statewide behavioral health community discharges (all service types) January 2012—June 2013

In September 2014, the OMH BHO Portal was updated to include hospital provider specific data. Click “Archived Reports” tab at BHO

Portal:

https://my.omh.ny.gov/webcenter/spaces/bho

46

Behavioral Health Managed Care Program Design

47

Behavioral Health Services for Adults will be Managed by:

Qualified health Plans meeting rigorous standards (several in partnership with a BHO)

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

Health and Recovery Plans (HARPs) for individuals with significant behavioral health needs

Plans may choose to apply to be a HARP with expanded benefits

Expanded benefit includes Home and Community Based Services (HCBS)

HARP members are eligible for enhanced Health Home Care Coordination

48

Qualified Managed Care Plan vs. Health and Recovery Plan (HARP)

Qualified Managed Care Plan HARP

Medicaid eligible

Benefit includes Medicaid state plan covered services

Organized as benefit within MCO

Management coordinated with physical health benefit management

Performance metrics specific to BH

BH medical loss ratio

Specialized integrated product line for people with significant behavioral health needs

Eligible based on utilization or functional impairment

Enhanced benefit package - All current PLUS access to HCBS

Specialized medical and social necessity/ utilization review for expanded recovery-oriented benefits

Benefit management built around higher need HARP patients

All HARP members eligible to be enrolled in HH

Performance metrics specific to higher need population and HCBS

Integrated medical loss ratio 49

Adult Project Status

Final RFQ for adults was distributed (with draft NYC HARP rates) on March 21, 2014

OMH: http://www.omh.ny.gov/omhweb/bho/phase2.html

DOH: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health_transition.htm

RFQ Applications were received on June 6, 2014

NYS is in the process of finalizing Plan designation for NYC

Start date

Adults NYC-April 1, 2015

Adults Rest of State - approximately six months later

Kids- January 1, 2016

50

Behavioral Health Benefit Package

Behavioral Health State Plan Services –Adults Inpatient - SUD and MH

Clinic – SUD and MH

Personalized Recovery Oriented Services (PROS)

Intensive Psychiatric Rehabilitation Treatment (IPRT)

Assertive Community Treatment (ACT)

Continuing Day Treatment (CDT)

Partial Hospitalization

Comprehensive Psychiatric Emergency Program (CPEP)

Opioid treatment

Outpatient chemical dependence rehabilitation

Rehabilitation supports for Community Residences (Not in the benefit package in year 1)

51

Menu of Home and Community Based Services in HARPs

Rehabilitation

Psychosocial Rehabilitation

Community Psychiatric Support and Treatment (CPST)

Crisis Intervention

Short-Term Crisis Respite

Intensive Crisis Intervention

Mobile Crisis Intervention

Habilitation

Empowerment Services and Peer Supports

Support Services

– Family Support and Training

– Non- Medical Transportation

Individual Employment Support Services

– Prevocational

– Transitional Employment Support

– Intensive Supported Employment

– On-going Supported Employment

Educational Support Services

Self Directed Services

52

Behavioral Health Transition Features Two Year Transition Period

Legislative and Contractual: Networking, contracting, and reimbursement requirements to support a stabilized two year transition period

Ensuring Adequate BH Networks: Network / Contracting Requirements

Important to BH transition Plans must allow members to have a choice

of at least 2 providers of each BH specialty service

– Must provide sufficient capacity for their populations

Contract with crisis service providers for 24/7 coverage

Plans contracting with clinics with state integrated licenses must contract for full range of services available

HARP must have an adequate network of Home and Community Based Services

BH Network requirements include:

Contracts with OMH or OASAS licensed or certified providers serving 5 or more members for a minimum of 24 months

Plans must contract for State operated BH ambulatory services

Treated as “Essential Community Providers”

Plans must network with:

All Opioid Treatment programs in their region to ensure regional access and patient choice where possible

Health Homes

54

Promoting Financial Stability Through Payment and Claiming Requirements

CLAIMING

Plan must be able to support BH services claim submission process. This includes training providers.

Plans must meet timely payment requirements

Plans must support web; and, paper based claiming.

HARP MLR - percentage in NYC is 89%

BH MLR- under development

PAYMENTS

Mainstream and HARP pay FFS government rates to OMH or OASAS licensed or certified providers for ambulatory services for 24 months

HARP capitation rate does not include HCBS package in first year. NYS will establish initial HCBS payment rates.

BH and HARP MLR

Mainstream Plans will have a BH MLR

HARP will have an integrated MLR

Plans must meet timely payment requirements

55

Supporting Access to Treatment and Recovery Support Services

56

Ensuring that mainstream plans are focused and prepared to effectively manage BH services

Working with plans to make Home and Community Based Services available to mainstream members

Mandating the use of the OASAS LOCATDR 3

Clinical level of care tool that assesses the intensity and need of services for an individual with a Substance Use Disorder

Supporting off site services in the OASAS system

Seeking Federal State Plan Amendment (SPA) approval to allow off-site services by moving from a Federal Clinic SPA authority to Federal Rehabilitation SPA authority

Outpatient treatment providers will still be authorized to provide OASAS services in their clinics but will also be able to provide these same services outside the four walls of the clinic

Network Training: Plans are Required to Train Behavioral Health Providers

Plans will develop and implement a comprehensive BH provider training and support program that includes:

Billing, coding and documentation assistance

Data interface

UM requirements

Evidence-based practices

HARPs train providers on HCBS requirements

Training coordinated through Regional Planning Consortiums (RPCs) when possible

RPCs are comprised of each LGU in a region, representatives of mental health and substance use disorder service providers, child welfare system, peers, families, health home leads, and Medicaid MCOs

RPCs work closely with State agencies to guide behavioral health policy in the region, problem solve regional service delivery challenges, and recommend provider training topics

RPCs to be created 57

Children’s Medicaid Managed Care Design Update

58

Children’s Proposed Benefits

New State Plan Services

New Home & Community Based Services

Mobile Crisis Intervention

Community Psychiatric Supports and Treatment (CPST)

Other Licensed Practitioner

Family Peer Support Services

Youth Peer Advocacy and Training

Psychosocial Rehabilitative Services

Care Coordination Skill Building

Family/Caregiver Support Services Planned Respite

Crisis Respite Day Habilitation

Prevocational Services Palliative Care

Supported Employment Services

Community Advocacy and Support

Non-Medical Transportation

Adaptive and Assistive Equipment

Accessibility Modifications

59

Preparing the field: NYS State Partnership with Managed Care Technical Assistance Center (MCTAC)

NYS has partnered with MCTAC as a training, consultation, and educational resource center that offers resources to ALL mental health and substance use disorder providers in New York State

The goal of MCTAC is to provide training and intensive support on quality improvement strategies, including business, organizational and clinical practices to achieve the overall goal of preparing and assisting providers with the transition to Medicaid Managed Care

60

New York State Behavioral Health Medicaid Managed Care Kickoff

61

Andrew Cleek, PsyD, McSilver Institute Charles Neighbors, PhD, MBA, CASA Columbia Meaghan Baier, MSW, Institute for Community Living Dan Ferris, MPA, McSilver Institute

MCTAC.info@nyu.edu http://www.MCTAC.org

Kickoff Agenda

• Medicaid Managed Care Technical Assistance Center (MCTAC) Introduction

• Phase 1: Critical Factors & Readiness Assessment

• MCTAC Training Series • Phase 2: Long Term Success • Change Management & the Role of Leadership • Discussion & Next Steps

62

Managed Care TAC (MCTAC) Overview

What is MCTAC? MCTAC is a training, consultation, and educational resource center that offers resources to all mental health and substance use disorder providers in New York State. MCTAC’s Goal Provide training and intensive support on quality improvement strategies, including business, organizational and clinical practices to achieve the overall goal of preparing and assisting providers with the transition to Medicaid Managed Care.

63

MCTAC • MCTAC is partnering with OASAS and OMH to provide:

– Foundational information to prepare providers for Managed Care

– Support and capacity building for providers • tools • group consultation • informational training • assessment measures

– Information on the critical domain areas necessary for Managed Care readiness

– Aggregate feedback to providers and state authorities

MCTAC Overview (cont.)

64

65

Managed Care Technical Assistance Center

Prior to the launch of MCTAC, a total of 340 or 69% of all adult and children’s clinics in New York State (n=496) have taken advantage of at least one CTAC offering.

The Children’s Technical Assistance Center is in its fourth year of

funding and has achieved a penetration rate of 78% (n=273).

In the last twenty-one months, the Adult Technical Assistance Center has had a penetration rate of 67% (n= 286).

More than 2,606 unique individuals and more than 7,389

participants have attended at least one of the 216 events offered by CTAC.

Previous Collaboration with Clinics

66

67

About CASAColumbia

CASAColumbia is: a science-based, multidisciplinary organization focused on transforming society’s understanding of

and responses to substance use and the disease of addiction

the foremost organization translating and disseminating research findings in order to: link ‘science to policy to practice’ bridge gaps that block progress by removing

stigma and improving outcome 68

CASAColumbia

Well-established national reputation in 3 major areas related to substance use and addiction:

1) translation of scientific findings and dissemination of information to the general public, policy makers, and providers (healthcare, education, social service) 2) policy reports and health services research (national surveys, regional program evaluation) focused on the financial and human costs of substance use and addiction on various sectors of American society 3) family-based adolescent substance use prevention and treatment research

69

CASAColumbia • Well-documented track record of increasing the impact of

scientific findings by getting them into the hands of: – medical and public health experts – state and local health commissioners – national public policy makers

• Select examples of pioneering reports widely distributed and cited over the past 20 years include: – Cost of Substance Abuse to America’s Health Care System: Medicare and

Medicaid – Addiction Medicine: Closing the Gap Between Science and Practice – Adolescent Substance Use: America’s #1 Public Health Problem – Shoveling Up: The Impact of Substance Use on Federal, State, and Local

Budgets

70

CASAColumbia Treatment System Reform Initiatives

• Implement practical, evidence-based interventions for risky substance use and addiction

• Our work is founded on the principles of: – a) evidence-based practice – b) use of process improvement strategies to adapt implementation to local

needs, and – c) data-based performance monitoring to guide implementation as well as

gauge success. • Collaborating with OASAS to develop tools for negotiating level of

addictions care decisions: LOCADTR • Collaborating with DOH, OASAS, AIDS Institute and OMH on evaluating

Health Home and other Medicaid reform efforts • Collaborating with OASAS and large healthcare system to implement

substance use screening and interventions

71

MCTAC Partners

72

Center for Practice Innovations www.practiceinnovations.org

• CPI helps agencies to implement evidence-based practices • Training for practitioners • Implementation support for managers

• Practices include: Care coordination; Employment; Motivational Interviewing; Engagement Strategies; Co-occurring substance use disorder and mental illness problems; Assertive community treatment; Wellness self-management; Suicide prevention

• • CPI’s reach is wide:

• Over 1300 programs • Over 182,000 online modules completed by 16,000 learners

• CPI will work closely with managed care companies to develop focused training in EBPs – this training will begin shortly • Managed care companies are already asking for information about

agency/program participation in CPI’s training activities

73

Drowning in acronyms

FIDA 74

MCTAC SCOPE

Licensing Office Number of Agencies

OASAS 444

OMH 545

OASAS and OMH 107

UNIQUE ORGANIZATIONS 887

75

76

Managed Care TAC (MCTAC) Goals

• Provide agencies with critical information necessary to prepare for the transition to Managed Care as early as April 1, 2015.

• Provide content training and support in preparing agencies for the implementation of Managed Care.

• Obtain a thorough assessment of agencies’ existing readiness to transition to Managed Care.

77

MCTAC will offer:

• Foundational information to prepare for Managed Care

• Support and capacity building for providers o tools o consultation o informational forums o assessment tools

• Critical information along each of the domain areas necessary for Managed Care readiness

• Feedback to providers and state authorities on readiness for Managed Care.

• MC TAC will serve as a clearing house for other Managed Care technical assistance efforts

78

• Hold Kick Off events around NY State • Distribute and collect a Managed Care Readiness

Assessment • Offer training series to providers based on two

levels of need: • Informational Training Series: Managed Care

Foundational Concepts Training Series • Intensive Training Series: Intensive

Implementation and Planning Action Learning Community

What will MCTAC do?

Level 1: Managed Care Foundational Concepts Training Series

Training topics will include:

• Understanding MCO Priorities

• MCO Contracting • Billing • Communication

/Reporting • IT System Requirements • Credentialing Process • Level of Care (LOC) Criteria

/ Utilization Management Practices

• Member Services/Grievance Procedures

• Medical Management • Quality

Management/Quality Studies/Incentive Opportunities

• Cash Flow Management • Revenue Cycle

Management • Access Requirements • Demonstrating

Impact/Value (Data Management & Evaluation Capacity)

79

A Conceptual Framework

Triple Aim of Improving Health Systems

• Improving the patient experience of care (including quality and satisfaction);

• Improving the health of populations; and

• Reducing the per capita cost of health care.

80

INFORMATIONAL TRAINING TOPICS

81

Understanding Managed Care

• Shifting from a volume based to an outcome based organization

• Clinical and Business Implications • Transitioning from Utilization Review to Utilization

Management • Understanding HARP and HCBS • Role and functions of physicians in a managed care

environment

82

Understanding Your Population

• What insurance plans are your clients currently enrolled in for physical health, or behavioral health as applicable

• Developing an agency wide profile of your population served and needs including HARP and HCBS

• Understanding your internal service patterns

• Have all your HARP eligible clients been enrolled?

83

Contracting

• Do you have current contracts with MCO’s? • Have you met with the MCO’s in your region? • What is your plan for developing contracts with all

MCO’s in your region? • How do insurance plans in your region differ across

factors such as authorization, billing, and utilization management?

• Reporting Requirements for each MCO • Access Requirements

84

Contracting (continued)

• Content unit beginning in mid-November • Online and in-person events scheduled • Initial forum will cover negotiating basics

and smart Managed Care contracting • Online sessions will include government

and provider perspectives • More information in your email and at

www.MCTAC.org

85

Business Operations

• Billing

• Cash Flow Management

• Revenue Cycle Management

• IT

86

Utilization Management

• Medical necessity

• Length of stay

• Clinical outcomes

• Level of Care

• Medical Management

• OASAS LOCADTR 87

Initial MCTAC Offerings

• Contracting with Managed Care – Basic MCO Contracting Facts

• MCO 101 – Panel of MCO execs – In person sessions throughout the state or

Web

• Billing

88

MCTAC Tools

• Sample MCO 101 Slides for Presentations to: – Board Members – Front Line Staff

• Guide to differences between MCO’s across Key Domains

• MCO 101 Quick Facts Sheet

89

–Trainings will begin in the fall and continue through Managed Care launch

» In-person and webinar based

–Follow-up consultation » Following each training topic, MCTAC will

provide at least one group consultation session to address questions and implementation challenges.

Foundational Concepts Training Series

90

Intensive Implementation and Planning Action Learning Community

– For select Informational Training topics, an intensive Learning Community will be offered in partnership with OMH/OASAS based on provider feedback and Readiness Assessment results. Some preliminary Learning Community topics include: • Finance/Business

– Cash-flow – Revenue Cycle Management – Billing

• Utilization Management

91

Intensive Implementation and Planning Action Learning Community

– Learning Communities will address topics that are the priority needs of providers

– Participants will have access to content from the Informational Training Series and can self-select which parts of the Learning Community to participate in based upon their interests/needs.

– The Intensive Training Series will begin through Managed Care launch and as needed ongoing

92

Intensive Implementation and Planning Action Learning Community

– Participants will be assigned to cohorts based on their areas of interest/need and level of readiness

– Learning Community Cohorts will participate in at least four implementation and problem solving sessions

– Participants will • develop an implementation plan • collect and report critical data elements

93

MCTAC Training Series

• Both the Informational and Intensive trainings will be offered again in 2015

• The training series will be repeated and provided to children’s providers later on.

• Both the Fall 2014 and Spring 2015 offerings are available to all Upstate and Downstate providers

94

MANAGED CARE READINESS ASSESSMENT

95

Managed Care Readiness Assessment Content Areas

• Understanding MCO Priorities • MCO Contracting • Communication /Reporting • IT System Requirements • Credentialing Process • Level of Care (LOC) Criteria / Utilization Management Practices • Member Services/Grievance Procedures • Medical Management • Quality Management/Quality Studies/Incentive Opportunities • Finance and Billing • Access Requirements • Demonstrating Impact/Value (Data Management & Evaluation Capacity)

96

Readiness Assessment • Readiness Assessment available in your folder • Was distributed online starting 9/10/14 • Were due back to MCTAC on October 10, and

are still being accepted on a rolling basis • Agencies are strongly encouraged to complete

the assessment as part of a management team meeting

• Individual agency information will be kept confidential

97

Managed Care Readiness Assessment

Data Collection and Analysis • Data collection: online through Qualtrics • Analyze collected data: Examine readiness

and preparedness for the transition to managed care and identify areas where additional support is needed

• Report: MCTAC will present aggregated data to relevant stakeholders

98

Timeline

99

MCTAC Timeline

Kick Off Events

September & October 2014

Readiness Assessment September & October 2014

Informational Training Series October ongoing

Intensive Training Series October ongoing

100

With the foundation and critical elements in place for operating under Managed Care, MCTAC will offer trainings on a range of topics that may include:

• Outcomes management • Emphasizing partnerships • New business structures • Development of new clinical & program

models • And more!

Looking ahead to 2015-2016

101

102

Change Management

Workforce Development

Continuous Quality

Improvement

Since 2011, CTAC has assisted with:

Change Management Leadership: Guiding an organization through rapid and

uncharted waters

104

So basically we need to :

105

• It is not unusual for an organization’s leadership to believe that it is engaged in promoting strategic change and for its workforce to experience shock change.

• Woodward, H. and Woodward, M.B. (1994). Navigating Through Change. NY: McGraw Hill.

Understanding the Impact of Change on the Workforce

106

• Designate a project team including: – Executive leadership, Finance & Clinic leadership,

and Evaluation staff when available

• Complete the readiness assessment and participate actively in MCTAC activities

• Commit to investing the time and effort needed to assess, diagnosis, improve, and monitor your organization’s operations, business practices, and financial performance

What Participants Can Do to Make the Most of MCTAC Supports

107

108

We want to hear from you!

• What topics, information, and tools would be most helpful to assist with the transition to managed care?

• What other technical assistance could we provide in the fall and beyond?

Discussion

The New York State Office of Mental Health and the Community Technical Assistance Center of New York are Announcing a New

Webinar Series: Reimagining Children’s Mental Health Services

Part I: What’s on the Horizon? November 7, 2014 – 1:30pm – 3:00pm

Presenter:

Donna Bradbury, MA, LMHC Associate Commissioner, Division of Integrated Community Services for

Children and Families New York State Office of Mental Health

Description: Learn about the current state of children’s mental health services and

important changes all child-serving organizations need to know. Learn how CTAC will provide supports to the full child-serving system in this transition.

Register at CTACNY.com

109

Thank you very much for your participation!

Contact us: MCTAC.info@nyu.edu Visit MCTAC’s website for more information and access to past webinars and trainings: http://www.CTACNY.com/ManagedCare

110