1. CCBHC Prospective Payment System (PPS) Technical Assistance Session 10 Webinar: Sustainability of Coverage in the Medicaid State Plan May 19, 2016 2:30-4:00 pm EST

2. I.Welcome II.Sustainability of Coverage in Medicaid a.Program Administration and Requirements b.Coverage Authorities c.Options for Continued Coverage III.Questions IV.PPS Webinar Schedule Webinar Agenda 2

3. Provide information useful to states in determining coverage options within the Medicaid state plan Goal of TA Session 3

4. Medicaid Program Administration Medicaid is a federal and state partnership Shared financing States have flexibility in the administration of their programs within broad federal guidelines Single state agency ‒Administers program ‒Serves as point of contact for CMS ‒Pays claims ‒Assures funds are available for the non federal share of payment 4

5. Medicaid State Plan State’s agreement/contract with CMS to administer the Medicaid program Includes mandatory provisions as well as options elected by states (eligibility groups, optional services, etc.) State plan amendments (SPA) are necessary to make any changes to eligibility, coverage, or reimbursement payment 5

6. Medicaid Requirements Amount, duration and scope – Sufficient to reasonably achieve purpose of service – Cannot be reduced based on diagnosis, type of illness or condition Comparability Statewideness Freedom of choice 6

7. Medicaid Coverage Authorities – Mandatory Benefits  Laboratory and X-ray services  Family planning services  Nurse midwife services  Certified pediatric and family nurse practitioner services  Freestanding birth center services (when licensed or otherwise recognized by the state)  Transportation to medical care  Tobacco cessation counseling for pregnant women 7  Inpatient hospital services  Outpatient hospital services  EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services  Nursing facilities services  Home health services  Physician services  Rural health clinic services  Federally qualified health center services

8. Medicaid Coverage Authorities – Optional Benefits 8  Prescription drugs  Clinic services  Physical therapy  Occupational therapy  Speech, hearing and language disorder services  Respiratory care services  Other diagnostic, screening, preventive and rehabilitative services  Podiatry services  Optometry services  Dental services  Dentures  Prosthetics  Eyeglasses  Chiropractic services  Other practitioner services  Private duty nursing services  Personal care  Hospice  Case management  Services for individual age 65 or older in an Institution for Mental Disease  Services in an intermediate care facility for Individuals with Intellectual Disabilities  TB related services  Inpatient psychiatric services for individuals under age 21  Other services approved by the Secretary*

9. Options for Continued Coverage 9 No distinct Medicaid state plan benefit called “Certified Community Behavioral Health Clinics” States may cover many of the individual component services through existing Medicaid coverage authorities pursuant to the rules of those authorities Submission of a Medicaid SPA may be necessary to ensure federal financial participation (FFP) is available for these services when provided in a CCBHC setting;

10. Options for Continued Coverage (cont’d) Facility benefits:  Clinic (42 CFR 440.90)  FQHCs (1905(a)(2)(B), 1905(l), 1861(aa), and 1902(bb) of Social Security Act Service/Practitioner benefits:  Rehabilitative (42 CFR 440.130(d))  Preventive (42 CFR 440.130(c))  Other licensed practitioner services (42 CFR 440.60(d))  Targeted case management (42 CFR 440.169 & 441.18) 10

11. Common Issues Care Coordination vs. TCM as a covered service Facility benefits vs. Service/Practitioner Benefits 11

12. State Plan Payment 12 Details to keep in mind:  Payment can be made only for services covered in the state plan.  Services may be paid fee for service (FFS) either individually or through a bundled payment.  The state plan must contain a comprehensive description of the FFS methodology that includes the effective date language.  The state may pay PPS for a bundle of BH services and may develop an incentive payment structure.  The state is not required to implement the PPS rate developed for demonstration payment.

13. State Plan Payment (cont’d) 13 If: Proposing PPS rate that pays for services across multiple Medicaid benefit categories Then: The state must have method to identify portion of rate that relates to each of the covered services for CMS-64 reporting. The state must establish procedures for tracking and monitoring utilization of the services paid through the PPS rate to ensure that it remains economic and efficient. If: PPS will be paid only to certain providers Then: State plan must contain the qualifying criteria that make a provider eligible to receive PPS.

14. Funding the Non Federal Share of Payment 14  CMS will ask the state how it will fund the non- federal share of payment.  The state may not use provider certified public expenditures (CPE) if it will pay using a PPS or other rate-based system. CPEs may be used only when paying based on cost.  Enhanced FMAP is not available for behavioral health services paid through the state plan or managed care.

15. State Plan Processes 15 State plan processes remain intact when a state proposes to modify payment for behavioral health services. The state: Must issue public notice in accordance with 42 CFR 447.205 Will submit its SPA using the normal, state plan process May request TA from CMS prior to submitting a SPA

16. Questions and Answers about Payment 16 Q1: Which elements of the CCBHC payment methodologies—daily/monthly rate, outlier payment and quality bonus payments (QBP)-- may the state implement through the state plan? A1: The state may implement all of these elements of the CCBHC rate methodologies through state plan payment.

17. Questions and Answers about Coverage 17 Q2: Is there any difference in how these rate components are treated in the state plan as compared to the demonstration? A2: Yes, all payment made using state plan authority is treated as payment for services, directly affecting the quality bonus payment (QBP). Specifically, as a service payment in the state plan the QBP must be counted toward any applicable Upper Payment Limit (UPL), such as the Clinic Services UPL.

18. Webinar Topic Date Open TA SessionThu 6/16, 2:30-4pm ET PPS Webinar Topics & Schedule *Topics and dates are subject to change 18

19. Questions 19

20. Mailboxes – CMS mailbox for PPS guidance-related questions: CCBHC-Demonstration@cms.hhs.gov CCBHC-Demonstration@cms.hhs.gov – CMS mailbox for Quality Based Payment-related questions: MACQualityTA@cms.hhs.gov MACQualityTA@cms.hhs.gov 223 PPS TA SharePoint Site Link Q&As posted at the 223 Landing Page on Medicaid.gov 223 Landing Page on Medicaid.gov Collaboration Tools 20