1. TIER ONE PROVIDERS Fee-for-Service Initiative

2. 2 Georgia Department of Behavioral Health and Developmental Disabilities REVISIONS NOTE: This information has been updated as of 6/10/2016. Providers should review this information thoroughly as some of it has revised.

3. 3 Georgia Department of Behavioral Health and Developmental Disabilities July 1, 2016 Transition Based upon current assessed risk:  Limited roll-out of Fee-For-Service effective July 1, 2016  Adult MH Core Benefit Package  Adult AD Core Benefit Package  Substance Abuse Intensive Outpatient Program  Psychosocial Rehabilitation - Individual and Group  Peer Support – Individual and Group and Whole Health and Wellness  Phased transition of other Specialty Services beginning in calendar year 2017  Phased transition of remaining GIA-based services to Fully Costed Reimbursement contracts beginning in calendar year 2017  Implementation of approval-based Supplemental Support Funds requests July 1, 2017

4. 4 Georgia Department of Behavioral Health and Developmental Disabilities Adult BH Core Benefits Package BH Assessment and Service Plan Development Psychological Testing Diagnostic Assessment Crisis Intervention Psychiatric Treatment (E&M) Nursing Services Medication Administration Psychosocial Rehabilitation - Individual Addictive Diseases Support Services Case Management Outpatient Services – Individual and Group Outpatient Services – Family Community Transition Planning Peer Support – Individual Peer Support – Whole Health and Wellness

5. 5 Georgia Department of Behavioral Health and Developmental Disabilities Tier One Provider Funding Maximum Reimbursement Limits  Maximum reimbursement limits are being assigned to providers as a statewide budgetary control mechanism. This limit provides a reasonable assurance that the state allocation for community behavioral health services is not exceeded on an annual basis.  Initial limits for FY17 will be based upon FY16 contracted values for the core benefit package and other selected services transitioning to FFS on July 1, 2016.  Maximum reimbursement limits will be reviewed for potential adjustment to allow for possible redirects of funding at mid- year and year-end.  Reviews will be based upon actual utilization data collected.

6. 6 Georgia Department of Behavioral Health and Developmental Disabilities Tier One Provider Funding Minimum Reimbursement Limits  Tier One providers will be eligible for one year of transitional revenue protection in the form of guaranteed minimum levels of reimbursement.  Minimum reimbursement limits for FY17 will be set based on 70% of a provider’s FY16 funding levels for the core benefit package and other services being transitioned to FFS on July 1, 2016. Actual earned revenues will be reviewed and compared to initial Minimum Reimbursement Limits at mid-year and year-end.  Any shortfall between actual earned revenues and Minimum Reimbursement Limits will be addressed through an increase in supplemental support funding at year-end or upon approved intermediate request by contractor.

7. 7 Georgia Department of Behavioral Health and Developmental Disabilities Tier One Provider Funding Supplemental Support Funding  Supplemental Support funding for FY17 contracts will carry forward from FY16 contracts  Adjustments will be made based upon required additional funding resulting from minimum reimbursement limits, if applicable Future FFS Transitions  Remaining services not transitioning to FFS on July 1, 2016 will transition to FFS or to fully-costed reimbursement beginning in calendar year 2017

8. 8 Georgia Department of Behavioral Health and Developmental Disabilities Provider MRL Accumulators Claims payment will be applied to provider’s Maximum Reimbursement Limit (MRL) accumulators based on diagnosis codes on claim (MH or AD). The diagnosis code(s) on a claim should represent the principle condition, problem or other reason the service being billed was intended to address. Claims paid under the fund sources SFAD (State Funds – Adult) and GACF (State Funds – Crisis) are included. Services falling under SFCA (State Funds – C&A), WTSO/WTSR (Women’s Treatment Outpatient & Residential), and TCMH/TCDC (Treatment Court – not required to report) are not included. The accumulators will add all claims paid until the MRL is reached. Once the MRL is reached, claims will become “pre-pay” and utilization is then tracked as state encounters.

9. 9 Georgia Department of Behavioral Health and Developmental Disabilities Providers with both MRL Accumulators MH and AD: The following section provides information specific to the implementation of Maximum Reimbursement Limit Accumulators for providers who will have an accumulator set up for both Mental Health and Addictive Disease services. Provider MRL Accumulators

10. 10 Georgia Department of Behavioral Health and Developmental Disabilities Providers with both MRL Accumulators MH and AD How claims are applied:  A mental health or addictive disease diagnosis code is required in Diagnosis Code 1 position on each claim.  Claims with two diagnosis codes will be split and 50% applied to each MRL when applicable (providers with both MH and AD funding accumulators). If one accumulator has been reached then only 50% of the claim will be paid.  Once the MRL has been reached, claims will be processed in pre-pay status and no payment will occur. The claim processes similar to state encounters and is tracked for utilization purposes. The scenarios on the next slides depict claims paying against MRL’s for MH and AD.

11. 11 Georgia Department of Behavioral Health and Developmental Disabilities Providers with both MRL Accumulators MH and AD Scenario Claim # Claim Amount MH MRL Cap Amt Applied to MRL MH Balance AD MRL Cap Amt Applied to MRL AD Balance 1a$150$100,000$150$99,850$50,000- 1b$125-$99,850$125$49,875 Remaining balances carried forward to next slide.

12. 12 Georgia Department of Behavioral Health and Developmental Disabilities Scenario Claim # Claim Amount MH MRL Cap Amt Applied to MRL MH Balance AD MRL Cap Amt Applied to MRL AD Balance 2a$84$100,000$84$99,766$50,000-$49,875 2b$54-$99,766$54$49,821 Remaining balances carried forward to next slide. Providers with both MRL Accumulators MH and AD

13. 13 Georgia Department of Behavioral Health and Developmental Disabilities Providers with both MRL Accumulators MH and AD Scenario Claim # Claim Amount MH MRL Cap Amt Applied to MRL MH Balance AD MRL Cap Amt Applied to MRL AD Balance 3a$90$100,000$45$99,721$50,000$45$49,776 3b$156$78$99,643$78$49,698 Remaining balances carried forward to next slide.

14. 14 Georgia Department of Behavioral Health and Developmental Disabilities Providers with both MRL Accumulators MH and AD Scenario Claim # Claim Amount MH MRL Cap Amt Applied to MRL MH Balance AD MRL Cap Amt Applied to MRL AD Balance 4a$66$100,000$66$99,577$50,000-$49,698 4b$112-$99,577$112$49,586 Remaining balances carried forward to next slide.

15. 15 Georgia Department of Behavioral Health and Developmental Disabilities Providers with both MRL Accumulators MH and AD Scenario Claim # Claim Amount MH MRL Cap Amt Applied to MRL MH Balance AD MRL Cap Amt Applied to MRL AD Balance 5a$70$100,000$0 $50,000$35$49,586 5b$32$16$99,850$0 See next slide for total accumulation.

16. 16 Georgia Department of Behavioral Health and Developmental Disabilities Applying Claims to Accumulators Once an accumulator reaches $0, subsequent claims become pre-pay and no longer paid fee for service. ScenarioClaim Amount MH MRL Cap Amt Applied to MRL MH Balance AD MRL Cap Amt Applied to MRL AD Balance 1a$150$100,000$150$99,850$50,000- 1b$125-$99,850$125$49,875 2a$84 $99,766-$49,875 2b$54-$99,766$54$49,821 3a$90$45$99,721$45$49,776 3b$156$78$99,643$78$49,698 4a$66 $99,577-$49,698 4b$112-$99,577$112$49,586 ….. 5a$70$0 $35$49,586 ….. 5b$32 $99,542$0 Note: The rows below the dashed line assume that the MRL has been reached.

17. 17 Georgia Department of Behavioral Health and Developmental Disabilities Providers with one MRL Accumulator MH or AD: The following section provides information specific to the implementation of Maximum Reimbursement Limit Accumulators for providers who will have a single accumulator set up for either Mental Health or Addictive Disease services. Provider MRL Accumulators

18. 18 Georgia Department of Behavioral Health and Developmental Disabilities Providers with one MRL Accumulator MH or AD How claims are applied:  A mental health or addictive disease diagnosis code is required in Diagnosis Code 1 position on each claim.  Claims with two diagnosis codes will be applied to the MRL accumulator regardless of the diagnosis on the claim.  For example, if a provider has AD funding only, one accumulator is set up. If a claim is to be paid the total amount of the claim is applied to the AD accumulator.  Once the MRL has been reached, claims will be processed in pre-pay status and no payment will occur. The claim processes similar to state encounters and is tracked for utilization purposes. The scenarios on the next slides depict claims paying against a single MRL accumulator.

19. 19 Georgia Department of Behavioral Health and Developmental Disabilities Providers with one MRL Accumulator MH or AD Scenario Claim # Claim Amount MRL Cap Amount Applied to MRLMRL Balance 1a$150$100,000$150$99,850 1b$125 $99,725 Remaining balance carried forward to next slide.

20. 20 Georgia Department of Behavioral Health and Developmental Disabilities Remaining balance carried forward to next slide. Providers with one MRL Accumulator MH or AD Scenario Claim # Claim Amount MRL Cap Amount Applied to MRLMRL Balance 1a$84$100,000$84$99,641 1b$54 $99,587

21. 21 Georgia Department of Behavioral Health and Developmental Disabilities Providers with one MRL Accumulator MH or AD Remaining balances carried forward to next slide. Scenario Claim # Claim Amount MRL Cap Amount Applied to MRLMRL Balance 1a$90$100,000$90$99,497 1b$156 $99,341

22. 22 Georgia Department of Behavioral Health and Developmental Disabilities Providers with one MRL Accumulator MH or AD Remaining balances carried forward to next slide. Scenario Claim # Claim Amount MRL Cap Amount Applied to MRLMRL Balance 1a$66$100,000$66$99,275 1b$112 $99,163

23. 23 Georgia Department of Behavioral Health and Developmental Disabilities Providers with one MRL Accumulator MH or AD See next slide for total accumulation. Scenario Claim # Claim Amount MRL Cap Amount Applied to MRLMRL Balance 1a$70$100,000$0 1b$32$0

24. 24 Georgia Department of Behavioral Health and Developmental Disabilities Applying Claims to Accumulators Once the accumulator reaches $0, subsequent claims become pre-pay and no longer paid fee for service. Scenario Claim # Claim Amount MRL Cap Amount Applied to MRLMRL Balance 1a$150$100,000$150$99,850 1b$125 $99,725 2a$84 $99,641 2b$54 $99,587 3a$90 $99,497 3b$156 $99,341 4a$66 $99,275 4b$112 $99,163 …. 5a$70$0 5b$32$0 Note: The rows below the dashed line assume that the MRL has been reached.

25. 25 Georgia Department of Behavioral Health and Developmental Disabilities Questions? Please submit any questions to FFS.questions@dbhdd.ga.gov