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Medicaid Coverage Expansion for SUD Services The San Mateo County Experience April 2013.

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Presentation on theme: "Medicaid Coverage Expansion for SUD Services The San Mateo County Experience April 2013."— Presentation transcript:

1 Medicaid Coverage Expansion for SUD Services The San Mateo County Experience April 2013

2 Overview Design of LIHP/MCE in SMC Design of LIHP/MCE in SMC Progress in core implementation areas Progress in core implementation areas Successes, challenges, lessons Successes, challenges, lessons Provider Readiness Provider Readiness Next Steps Next Steps

3 What is “MCE” MCE = Medicaid Coverage Expansion MCE = Medicaid Coverage Expansion Low income health program for adults who have incomes from 0-133% of the Federal Poverty Level. Low income health program for adults who have incomes from 0-133% of the Federal Poverty Level. MCE is a "bridge" program created by the State of California and the federal government for individuals who are expected to qualify for expanded Medicaid benefits in 2014,under the new federal health care reform law. MCE is a "bridge" program created by the State of California and the federal government for individuals who are expected to qualify for expanded Medicaid benefits in 2014,under the new federal health care reform law.

4 Covered Substance Use Services* (San Mateo County’s LIHP/MCE Program) Assessment Assessment Behavioral Health Integration Behavioral Health Integration Case Management Case Management Collateral Services Collateral Services Day Care Rehabilitation Day Care Rehabilitation Detoxification Detoxification Group Counseling Group Counseling Individual Counseling Individual Counseling Medication Assisted Treatment Medication Assisted Treatment Narcotic Replacement Therapy (Methadone) Narcotic Replacement Therapy (Methadone) Outpatient Treatment Outpatient Treatment Residential Acute Stabilization Residential Acute Stabilization Residential Perinatal Treatment Residential Perinatal Treatment Residential Treatment Including Detoxification Residential Treatment Including Detoxification Screening and Intervention Screening and Intervention *CA Dept of Health Care Services, San Mateo County LIHP Contract, Exhibit A, Attachment 15, 8/18/11

5 MCE: Year in Review Core Implementation Areas Eligibility and Enrollment Eligibility and Enrollment Medical Necessity Medical Necessity Treatment Authorization Treatment Authorization Treatment Services Treatment Services Service Billing Service Billing Documentation Documentation Managing the Budget Managing the Budget Reporting Reporting Electronic Health Records Transition Electronic Health Records Transition

6 Eligibility & Enrollment Streamlined health coverage application process for homeless and AOD providers Streamlined health coverage application process for homeless and AOD providers Successful interagency partnership among HPSM, CHA, HCU, BHRS, and AOD Providers Successful interagency partnership among HPSM, CHA, HCU, BHRS, and AOD Providers FY 11/12 FY 11/ Clients enrolled via AOD provider sites385 Clients enrolled via AOD provider sites 70% via AOD Provider-HCU Partnership 70% via AOD Provider-HCU Partnership 30% via Palm Detox - BHRS Health Insurance Outreach Program Partnership 30% via Palm Detox - BHRS Health Insurance Outreach Program Partnership Unknown # enrolled by CHAs at county clinicsUnknown # enrolled by CHAs at county clinics

7 Monthly Enrollment into Health Coverage

8 Enrollment & Eligibility Challenges and Lessons Transitory nature of population Transitory nature of population Picture Identification requirements Picture Identification requirements Failure to disclose all income (ie: unemployment) Failure to disclose all income (ie: unemployment) Individuals with benefits in neighboring counties Individuals with benefits in neighboring counties Delayed notification of coverage to providers Delayed notification of coverage to providers No automated “back-end” eligibility verification once billing is submitted No automated “back-end” eligibility verification once billing is submitted

9 Medical Necessity Developed by team of BHRS, Providers, and clinical experts Developed by team of BHRS, Providers, and clinical experts Informed by ASAM, medical necessity requirements of other health insurers. Informed by ASAM, medical necessity requirements of other health insurers. Provider capacity expansion Provider capacity expansion Diagnosis - staffing implications and recommend language change to diagnostic impression Diagnosis - staffing implications and recommend language change to diagnostic impression Staff Credentialing Requirements (AOD certified vs licensed) Staff Credentialing Requirements (AOD certified vs licensed)

10 Covered SUD Services Implementation Status/ Comments Assessment Implemented as billable service within OP Tx Behavioral Health IntegrationService and Medical Necessity TBD Case Management Implemented as billable service within OP Tx Collateral Services Implemented as billable service within OP Tx Day Care Rehabilitation Implemented Detoxification Social Model Residential Implemented Group Counseling Implemented as billable service within OP Tx Individual Counseling Implemented as billable service within OP Tx Medication Assisted TreatmentService, Medical Necessity, covered Rx- TBD Narcotic Replacement Therapy (Methadone) Implemented NRT Maintenance and Detox using DMC requirements, MCE in progress Outpatient Treatment Implemented Residential Acute Stabilization Implemented Residential Perinatal Treatment Implemented Residential Treatment Including Detoxification Implemented separately, not as a combined service Screening and InterventionNot implemented; Service and Medical Necessity TBD

11 Treatment Authorizations Prior treatment service authorizations required. Prior treatment service authorizations required. ACCESS Call Center processes MCE Authorization and Re- Authorization Requests, via Avatar ACCESS Call Center processes MCE Authorization and Re- Authorization Requests, via Avatar Service Packages, initial authorization period Service Packages, initial authorization period Residential Detoxification Services– 5 calendar days maximumResidential Detoxification Services– 5 calendar days maximum Residential Services – 60 calendar day (2 months) maximumResidential Services – 60 calendar day (2 months) maximum Intensive Outpatient Services – 120 day (4 months) maximumIntensive Outpatient Services – 120 day (4 months) maximum Outpatient Services– 6 months maximumOutpatient Services– 6 months maximum Narcotic Replacement Treatment – 1 year maximumNarcotic Replacement Treatment – 1 year maximum Retroactive “auth” requests permitted when client MCE is “pending enrollment” up to 90 days from date of first service. Retroactive “auth” requests permitted when client MCE is “pending enrollment” up to 90 days from date of first service.

12 Approved MCE Treatment Authorizations, by Modality

13 MCE Service Billing $2,894,627 – FY 11/12 billing total $2,894,627 – FY 11/12 billing total Represents $1,447,313 in new federal funds for SUD treatment in San Mateo CountyRepresents $1,447,313 in new federal funds for SUD treatment in San Mateo County Limited provider experience tracking and billing for services by the minute (OP only) Limited provider experience tracking and billing for services by the minute (OP only) Temporary “scantron” was up for billing, until transition to Avatar was completed Temporary “scantron” was up for billing, until transition to Avatar was completed

14 Medicaid Expansion in 2014 The good news…the Supreme Court upheld the Affordable Care Act. The good news…the Supreme Court upheld the Affordable Care Act. In 2014, the estimated 20% of uninsured Californians will be able to obtain health coverage via the Exchange or Medicaid expansion. In 2014, the estimated 20% of uninsured Californians will be able to obtain health coverage via the Exchange or Medicaid expansion. MCE SUD benefit and provider requirements –still pending State determination MCE SUD benefit and provider requirements –still pending State determination CA considering “State” verses “County” option CA considering “State” verses “County” option

15 SUD Provider Readiness Changing face of partners and referrals sources, from criminal justice to primary care Changing face of partners and referrals sources, from criminal justice to primary care Credentialing of staff – State ADP requirements vs. health insurance requirements (licensing); ability to diagnose. Credentialing of staff – State ADP requirements vs. health insurance requirements (licensing); ability to diagnose. Treatment Program design – care based on individual needs, not on “program design” (ie: 90 day program) Treatment Program design – care based on individual needs, not on “program design” (ie: 90 day program) Documentation of medical necessity and services Documentation of medical necessity and services Knowledge of billing codes Knowledge of billing codes Lack relationships with private insurers, primary care providers. Lack relationships with private insurers, primary care providers.

16 Next Steps: Primary Care Navigate the primary care systemNavigate the primary care system Develop relationshipsDevelop relationships Establish referral & communications protocols (bi-directional)Establish referral & communications protocols (bi-directional) Provide outreach materials to PCPProvide outreach materials to PCP Expanding medication assisted treatmentExpanding medication assisted treatment Improve physical and mental health of SUD clients through greater coordinationImprove physical and mental health of SUD clients through greater coordination

17 Thank you! Clara Boyden SMC Behavioral Health & Recovery Services


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