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NC Department of Health and Human Services DMA Division of Medical Assistance: Integrated Care Workgroup Courtney Cantrell, PhD Assistant Director for.

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Presentation on theme: "NC Department of Health and Human Services DMA Division of Medical Assistance: Integrated Care Workgroup Courtney Cantrell, PhD Assistant Director for."— Presentation transcript:

1 NC Department of Health and Human Services DMA Division of Medical Assistance: Integrated Care Workgroup Courtney Cantrell, PhD Assistant Director for Behavioral Health Division of Medical Assistance (DMA)

2 DMA Division of Medical Assistance The mission of the Division of Medical Assistance (DMA) is to provide access to high quality, medically necessary health care for eligible North Carolina residents through cost-effective purchasing of health care services and products.

3 DMA Medicaid & NCHC Programs Medicaid is a health insurance program for low-income individuals and families who cannot afford health care costs. Medicaid serves low-income parents, children, seniors, and people with disabilities. ***Stay enrolled!!Medicaid N.C. Health Choice for Children (NCHC) is a free or reduced price comprehensive health care program for children.N.C. Health Choice for Children (NCHC) –***NC Tracks!!

4 DMA Medicaid Policy Subject to Federal Laws and Social Security Act, as well as state statutes; often follows Medicare State plan submitted to Centers for Medicare and Medicaid Service (CMS) for approval (unmanaged visits, services covered, providers who can provide services, etc) WAIVERS – allow us more flexibility to do things that would not be approved in a regular state plan

5 DMA Medicaid Waivers Waive provisions of Social Security Act (SSA) –Each waiver number refers to a section of SSA –Each waives provisions of Section 1902 (requirements for State Plans)

6 DMA NC Medicaid Waiver for MH/SA/IDD Services Medicaid Program follows Title XIX of the SSA Medicaid Managed Care Program under CFR 438 DMA gets a 1915b/c waiver from CMS (Centers for Medicare & Medicaid) (b) waiver allows DMA to contract with a managed care vendor (LME) for oversight of mh/sa/dd services in their counties. PIHP: Prepaid Inpatient Health Plan (c) Waiver allows DMA to offer HCBS (habilitation) DMA monitors the company (LME-MCO) to make sure that they follow all Medicaid rules. CMS monitors DMA (follow SSA)

7 DMA 5

8 Covered Benefit Package All services found in the 8x series of DMA Clinical Coverage Policies - -regular outpatient and enhanced services*** LME-MCO cannot be more restrictive than DMA Clinical Coverage Policy Audits should be based at least on DMA policy

9 DMA Covered Benefit Package –Inpatient Behavioral Health Services (DMA Clinical Coverage Policy 8B) –Inpatient services for the treatment of mental health and substance abuse disorders and developmental disabilities –Hospital Emergency Department (ED) services: Each LME-MCO is responsible for all facility, professional, and ancillary charges for services delivered in the emergency department to individuals with a discharge diagnosis ranging from 290 to 319.

10 DMA Covered Benefit Package –Outpatient Behavioral Health Services including all services provided by psychiatrists for recipients with a diagnosis in the range (DMA Clinical Coverage Policy 8C) Excluded: E&M codes by physicians (except psychiatrists) –even if dx is NOTE: Co-located BH providers will need to enroll with the LME-MCO

11 DMA Covered Benefit Package –Psychiatric Residential Treatment Facilities (PRTFs) (DMA Clinical Coverage Policy 8D1) –Therapeutic Foster Care (TFC) (DMA Clinical Coverage Policy 8D2) –Residential Child Care Levels II group, III, IV (DMA Clinical Coverage Policy 8D2)

12 DMA Excluded Services/Populations Early Intervention Services (0-2) are currently excluded –CDSA, including case management –CBRS –Outpatient MH services Very small #s of claims FQHCs are excluded Any BH service for children 3-5 are included –INPT, OTPT, Enhanced, residential

13 DMA DMA Reporting- B Waiver Use of Services –Mental Health Utilization – Inpatient Discharges and Average Length of Stay* –Mental Health Utilization – Percentage of Members Receiving Inpatient, Intermediate Care, Ambulatory and Other Support Services* –Chemical Dependency Utilization – Inpatient Discharges and Average Length of Stay* –Chemical Dependency Utilization - Percentage of Members Receiving Inpatient, Intermediate Care, Ambulatory and Other Support Services –Integrated Care

14 DMA Where is Integrated Care? and are billed by physicians directly to DMA (provided incident-to by the BH provider) All therapy codes (covered under 8x policies) are billed to the LME-MCO Contractual expectation that LME-MCOs support Integrated Care by reporting Integrated Care efforts annually Adjustments made to Clinical Coverage Policy 8C (no CCA for brief interventions in primary care clinic) Working through Provider Services to help with enrollment of BH agencies as CCNC medical homes ***Be careful to still heed the rules – if you are a BH provider (LCSW, Psychiatrist, etc) you can only direct-bill the LME-MCO; non-physician BH provideres cannot be enrolled as a physician group.)

15 DMA The Future: Partnership for a Healthy North Carolina Built based on over 160 responses to RFI Improve behavioral and physical health care outcomes Build on gains and innovations in community-based care and take it to the next level *Look at each person as a whole, treating behavioral and physical health needs in a collaborative way to improve the health of each individual.

16 DMA The Future: Partnership for a Healthy North Carolina Person-Centered –single entry point into system Recipient CHOICE of 3-ish statewide Comprehensive Care Entities that treats the whole person CCE provides functional needs assessment at single entry point Comprehensive care focused on outcomes (backed by strong contract) Customer Service: simplified for providers and patient-centered

17 DMA OnGoing Efforts Get Involved! Get to know what can be billed and when; read and understand policy (we can help); know your value ($) Give us Feedback! Systems are complex; let us know if something isn’t working or if you find something that could be improved Periodically policies go up for public review—feedback is carefully considered

18 DMA Medicaid/DMA Contacts Courtney Cantrell, PhD Assistant Director for Behavioral Health


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