Presentation on theme: "Rusty Selix California Council of Community Mental Health Agencies"— Presentation transcript:
1ACA, Realignment of EPSDT, Parity, Mild/Moderate to HMOs It’s a Whole new world, Or is it? Rusty SelixCalifornia Council ofCommunityMental Health AgenciesCMHACY 2014
2ACA and MH Federal Parity MediCal 100% FFP for low income adults not already eligible through disability or childrenIncludes TAY – foster care graduatesEliminates pre existing conditions as barrier to private insuranceHealthy families to MediCalFull parity for all plans- SUD MediCal
3MediCal Managed Care Expanded Covers whatever is medically necessary but does not meet county mental health standard of potential functional impairment (for adults)Children slightly broaderMedication Management/ Mild/moderatePlans have formed modest networksMedicare rates - enough for otherswithout our members in most countiesSanta Clara providers included at county rates
4MOUs between counties and plans Establish screening, assessment, referralsRight now can vary by countyState and plan standardization likely soonNo one falls between the cracksOne or the other must provide the careCould have disputes over paymentsMore will ask plans for careCounty responsibilities unchanged
5Screening and Assessment No current state requirement for kidsScreening tools by plans and countiesAssessment by MH professional by eithergenerally by planPlan either provides or refersReferral to county then to providerProvider authorization from plan or county
6Higher Costs Under Counties Commercial contracts have lower overheadLess documentation requiredOther states have similar patternPlans still must meet CMS Medicaid rulesState oversight different – what can we learnState and counties have added requirementsProviders can set up separate corporation
7Future Structural Changes? No one is proposing an end to carve outCMS letter based on audits and lack of actionService Integration under current financingNeed to learn how plans comply with CMS on billing with much lower costsFederal Financing structure could change from fee for service to capitationMight require competitive bidding on all services
8Goal of Seamless Integration Screening in primary careFor adults includes SBIRT and PHQ-2Children nothing required yetEPSDT Performance Outcomes to addressEvaluation by health planReferrals, co-location or warm hand offWho will be missed?What are issues and challenges?
9End Fail First System?People currently in public mental health system get referred after hitting a bottomSpecial ed, child welfare, juv. justice, hospitalSubstantial functional impairment at intakeAlmost always SED condition that has been present and diagnosable for yearsMental Health system itself can’t change this
10Help at First Possible Sign School mental health partnerships can identify and support all childrenGet help years before they need special edPrimary care and ER see almost everyoneUniversal screening and coordination can identify mental illnesses early in their onsetMore people will be referred for careLess disability and less long term costs
11Nearly All Will Meet County Criteria – my belief Most common MH treatment is prescription for anti –depressant by primary care MDMost so called mild – moderate will not result in a referral to MH professionalMost of MH by plans will be medication management for ADHDI could be wrong
12Realignment Formula Adjustments EPSDT and Alcohol & Drug are sub allocation entitlements inside Behavioral Health Account of 2011 RealignmentFor 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 fundsState still needs to clarify so counties don’t think $$ are capped –letter promised soonWhen will state do the allocations?
13State HHS call to Patrick Gardner Mike Wilkening Undersecretary calledClosing in on a decision expected in next few daysMemorialized in ACIN - letter to countiesReimburse counties out of this year's growth account for net expenditures above the total allocation for behavioral sub account programs. Expect letter to address considerations for future growth allocations that include:incentives for EPSDT investment and improving access and performance, probably tied to the POS process.
14Realignment Growth is Growing MH share of growth was limited until child welfare got $200 million of growthWill be met in two years instead of 3MH will get larger share of growth from 14-15First call on growth to satisfy net growth in EPSDT and Alcohol & DrugReduce base for underspending countiesUnclear about adult MediCalRest to counties by formula
15Katie A and Realignment Implementation starting$$ were included in realignmentPart of EPSDTQuestions about funding adequacyPossible augmentation through claim/suit under Prop 30 if it is viewed as new mandate
16EPSDT Outcomes Subject matter experts meeting regularly First phase uses existing dataAfter that a choice between developing priority additional data like Adult System of Care or build something more comprehensive statewideSpecial Katie A requirementsScreening and referral elements
17Excellence in Mental Health Act Just passed Congress and signed into lawPart of Medicare payment for MDs lawCreates FQBHC funding intended to approximate federal status for FQHCsStates to get 90% FFP for outpatient MH and SUD for SED/SMI for 2 yearsDetails through 2015 regs and 2016 plansCould be worth $$ Billions in CaliforniaEfforts to make permanent and nationwide
18Many Terms need to be defined Can a county be an FQBHC or must certification be for each specific locationWhat is Serious Mental IllnessWhat services are coveredInpatient and residential excludedMust serve all on sliding scaledoes that include undocumented immigrants?
19Future full of hope and possibility Screening and early identification seems certain to become a normTAY can keep MediCalFunding picture brighterOutcomes will improve careAddress paperwork burden?Coordination and integration growingPrimary Care + Schools + Alcohol and DrugOpportunity to serve whole family
20Contact InformationRusty Selixext. 0 or cellMichele Petersonext. 111 or cell