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Rusty Selix California Council of Community Mental Health Agencies CMHACY 2014 ACA, Realignment of EPSDT, Parity, Mild/Moderate to HMOs It’s a Whole new.

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Presentation on theme: "Rusty Selix California Council of Community Mental Health Agencies CMHACY 2014 ACA, Realignment of EPSDT, Parity, Mild/Moderate to HMOs It’s a Whole new."— Presentation transcript:

1 Rusty Selix California Council of Community Mental Health Agencies CMHACY 2014 ACA, Realignment of EPSDT, Parity, Mild/Moderate to HMOs It’s a Whole new world, Or is it?

2 ACA and MH Federal Parity MediCal 100% FFP for low income adults not already eligible through disability or children Includes TAY – foster care graduates Eliminates pre existing conditions as barrier to private insurance Healthy families to MediCal Full parity for all plans- SUD MediCal 2

3 MediCal Managed Care Expanded Covers whatever is medically necessary but does not meet county mental health standard of potential functional impairment (for adults) – Children slightly broader Medication Management/ Mild/moderate Plans have formed modest networks – Medicare rates - enough for others – without our members in most counties – Santa Clara providers included at county rates 3

4 MOUs between counties and plans Establish screening, assessment, referrals Right now can vary by county State and plan standardization likely soon No one falls between the cracks One or the other must provide the care Could have disputes over payments More will ask plans for care County responsibilities unchanged 4

5 Screening and Assessment No current state requirement for kids Screening tools by plans and counties Assessment by MH professional by either – generally by plan Plan either provides or refers Referral to county then to provider Provider authorization from plan or county 5

6 Higher Costs Under Counties Commercial contracts have lower overhead Less documentation required Other states have similar pattern Plans still must meet CMS Medicaid rules State oversight different – what can we learn State and counties have added requirements Providers can set up separate corporation 6

7 Future Structural Changes? No one is proposing an end to carve out CMS letter based on audits and lack of action Service Integration under current financing Need to learn how plans comply with CMS on billing with much lower costs Federal Financing structure could change from fee for service to capitation – Might require competitive bidding on all services 7

8 Goal of Seamless Integration Screening in primary care – For adults includes SBIRT and PHQ-2 – Children nothing required yet – EPSDT Performance Outcomes to address Evaluation by health plan Referrals, co-location or warm hand off Who will be missed? What are issues and challenges? 8

9 End Fail First System? People currently in public mental health system get referred after hitting a bottom Special ed, child welfare, juv. justice, hospital Substantial functional impairment at intake Almost always SED condition that has been present and diagnosable for years Mental Health system itself can’t change this 9

10 Help at First Possible Sign School mental health partnerships can identify and support all children Get help years before they need special ed Primary care and ER see almost everyone Universal screening and coordination can identify mental illnesses early in their onset More people will be referred for care Less disability and less long term costs 10

11 Nearly All Will Meet County Criteria – my belief Most common MH treatment is prescription for anti –depressant by primary care MD Most so called mild – moderate will not result in a referral to MH professional Most of MH by plans will be medication management for ADHD I could be wrong 11

12 Realignment Formula Adjustments EPSDT and Alcohol & Drug are sub allocation entitlements inside Behavioral Health Account of 2011 Realignment For future years total growth is adjusted by spending on those programs and each county’s share of growth is adjusted by its utilization of those funds State still needs to clarify so counties don’t think $$ are capped –letter promised soon When will state do the allocations? 12

13 State HHS call to Patrick Gardner Mike Wilkening Undersecretary called Closing in on a decision expected in next few days Memorialized in ACIN - letter to counties Reimburse counties out of this year's growth account for net expenditures above the total allocation for behavioral sub account programs. Expect letter to address considerations for future growth allocations that include: – incentives for EPSDT investment and improving access and performance, probably tied to the POS process. 13

14 Realignment Growth is Growing MH share of growth was limited until child welfare got $200 million of growth Will be met in two years instead of 3 MH will get larger share of growth from First call on growth to satisfy net growth in EPSDT and Alcohol & Drug Reduce base for underspending counties Unclear about adult MediCal Rest to counties by formula 14

15 Katie A and Realignment Implementation starting $$ were included in realignment Part of EPSDT Questions about funding adequacy Possible augmentation through claim/suit under Prop 30 if it is viewed as new mandate 15

16 EPSDT Outcomes Subject matter experts meeting regularly First phase uses existing data After that a choice between developing priority additional data like Adult System of Care or build something more comprehensive statewide Special Katie A requirements Screening and referral elements 16

17 Excellence in Mental Health Act Just passed Congress and signed into law Part of Medicare payment for MDs law Creates FQBHC funding intended to approximate federal status for FQHCs States to get 90% FFP for outpatient MH and SUD for SED/SMI for 2 years Details through 2015 regs and 2016 plans Could be worth $$ Billions in California Efforts to make permanent and nationwide 17

18 Many Terms need to be defined Can a county be an FQBHC or must certification be for each specific location What is Serious Mental Illness What services are covered Inpatient and residential excluded Must serve all on sliding scale – does that include undocumented immigrants? 18

19 Future full of hope and possibility Screening and early identification seems certain to become a norm TAY can keep MediCal Funding picture brighter Outcomes will improve care – Address paperwork burden? Coordination and integration growing – Primary Care + Schools + Alcohol and Drug – Opportunity to serve whole family 19

20 Contact Information Rusty Selix ext. 0 or cell Michele Peterson ext. 111 or cell


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