1. Behavioral Heath Solutions for Medical Health Plans Mary Ruiz, President/CEO, Manatee Glens 2014 Guide to Behavioral Health Conference Orlando Florida

2. Florida’s Medicaid Managed Medical Assistance

3. Florida’s General Plans Managed Medical Assistance Amerigroup (Wellpoint) Better Health (PSN) Coventry (Aetna) First Coast Advantage (PSN Shands) Humana Integral (PSN FQHC) Molina

4. Florida’s General Plans Managed Medical Assistance Preferred Medical (HMO) Prestige (Blue Cross) SFCCN (PSN) Simply (HMO) Sunshine (Centene) United Health Staywell (Wellcare)

5. Florida’s Specialty Plans Managed Medical Assistance Clear Health Alliance HIV/AIDS (Simply) Freedom Health Duals Chronic (HMO) Magellan Complete SPMI Positive Healthcare Florida HIV/AIDS Sunshine Health Plan Child Welfare (Centene) Children’s Medical Services Chronic (FL Department of Health)

6. Florida’s Medicaid Managed Medical Assistance

7. Community Mental Health Handbook Benefits Targeted Case Management Handbook Benefits Fee for Service Formulary for One Year No PCP Referral for BH Services—direct access required Behavioral Health Benefits

8. Florida’s Medicaid Managed Medical Assistance Substance Abuse Child Welfare Overlay Comp Assessment Transportation Therapeutic Foster Care Statewide Inpatient Psychiatric Therapeutic Group Fee for Service To Managed Care

9. Florida’s Medicaid Managed Medical Assistance Access Standards No Wait List Urgent One Day Sick Care One Week Well Care One Month

10. MMA Behavioral Health Coordination Contract Requirements State hospital 6 months of last 36 months 2 admissions to state hospital in 36 months 3 admissions to crisis, SRT or inpatient psych in 12 months Comorbid polypharmacy Exceed prescription limits

11. MMA Behavioral Health Contract Requirements County 24/7 emergency service with RN and on call behavioral health specialist ALF community living support plan and access to Drop In Centers Outreach and care management for non TCM clients (homeless, ALF, state hospital, jails, juvenile justice) Participation in DCF Planning Processes SIPP, State Hospital

12. Medicaid Health Plans of America Transition Coaches & Peer Bridgers (Optum) Peer Led Warm Line (Centene) Pediatric Residential Treatment Diversion (Optum Tennessee) Health Risk Assessment SMI (Centene) Best Practices Compendium Serious Mental Illness

13. Provider Challenges Lower Rates Increased Utilization Management Staff Attrition to Plans Increased Admin Costs Decreased Cash Flow Lower Collection Rates Inclusion in Networks

14. System Challenges End of Medical Loss Ratio for Behavioral Health Increased Spend on Medical Over Behavioral Health Increased Spend on BH Pharmacy over BH Hospital Disincentive for Risk Share Loss of Transparency on Total Behavioral Spend and Practices Workforce

15. New Possibilities? Pay for Performance Primary Care Coordination Telemedicine Substitute Services Healthy Behaviors Mental Health Excellence Act

16. Pay for Performance System Does it improve outcomes? How can outcomes differ if plan is the same? What are the right payment models? Provider What is the real total cost of care? Does the data bear up? What innovations are needed to move outcomes?

17. Florida MMA Contracted Quality Measures Depression Strategies Care, screening, or test Pharmacy/Lab Reports Peer Support Psycho Education Medication Management Care Management Cognitive Behavioral Adults newly diagnosed with depression and treated with an antidepressant who received the following:  Effective acute phase: filled sufficient number of Rx to allow for 84 days of continuous therapy.  Effective continuation phase: filled sufficient number of Rx to allow for 180 days of continuous therapy. To qualify as a new diagnosis, 2 criteria must be met:  A 120-day (4 month) negative diagnosis history on or before the start date and a 90-day (3 month) negative medication history on or before the start date

18. Florida MMA Contracted Quality Measures Mental illness StrategiesCare, screening, or test Pharmacy/Lab Reports Family Education Medication Management Care Management Parenting Support Respite Children 6-12 years who received an initial prescription for ADHD medication and:  Received at least one follow-up visit with a prescriber within 30 days of initiation of medication  Remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two more follow-up visits between four weeks and 9 months

19. Florida MMA Contracted Quality Measures Alcohol and other drug dependence StrategiesCare, screening, or test Intervention Outreach Harm Reduction Motivational Enhancement Peer Support Medication Assisted Therapy Patients 13 and older diagnosed with alcohol and other drug dependence who:  initiate treatment within 14 days of diagnosis  receive two additional AOD services within 30 days of initiation

20. Florida MMA Contracted Quality Measures Mental illness StrategiesCare, screening, or test Care Management Respite Peer Support Recovery Plan Family Education Patients 6 and older discharged from an inpatient mental health admission and receive:  One follow-up encounter with a mental health provider within 7 days after discharge.  One follow-up encounter with a mental health provider within 30 days after discharge.

21. Pay for Performance MMAContractPenalties $10,000 below 50% per performance group Liquidated damages $1.25- $3.50 per member Failure for face to face with case manager/bh provider $5,000 each occurrence

22. Pay for Performance Payment Models Payment Model Enhanced Rate Monthly Cap Rate for Care Management Monthly Bundled Payment for Treatment Capitation Precedence Mental Health Excellence HMO Primary Care Florida BNET Prepaid Mental Health Plans

23. Pay for Performance Payment Models Payment Model Enhanced Rate Monthly Cap Rate for Care Management Monthly Bundled Payment for Treatment Capitation Performance Targets Access to Care Adherence or High Risk High Cost Medical Home

24. Primary Care Coordination PCP Concerns Mandatory assignment of a PCP required 67% of PCP’s say they have no behavioral health referral 30-50% of patients refuse behavioral health referral Psychiatrists don’t interrupt sessions to take physician calls

25. Primary Care Coordination PCP Adherence Rates 20% of patients don’t fill PCP scripts 50% adherence blood pressure medications 20% inhalant compliance pediatric asthma 56% diabetic adherence in the year following diagnosis

26. Primary Care Coordination PCP Outreach Build Primary Care Data Base Direct Sales Marketing Referral Concierge Lunch and Learns Tours CME/Medical Society Talks Troubleshoot Referral Relationship

27. Primary Care Coordination PlanDemonstrationProjects Adherence for asthma, diabetes, cardiac patients Comorbid polypharmacy Substance abuse All cause readmissions High cost Medical home features to PCP practice Health risk assessments for BH caseload

28. Primary Care Coordination PlanDemonstrationProjects Body Mass Index Immunization Status HbA1c Levels Blood Pressure Risk Identification Functional Outcomes Medication Compliance

29. Telemedicine 1. Community Mental Health Handbook 2. MMA Contracts 3. Provider Contracts Allowed for behavioral health, dental and physician services Hub and spoke Telemedicine modifier code for sixteen services Optional not required Medicaid prohibition to pay for equipment

30. Best Bets for Telemedicine Enhanced Rate High Volume Collaborative Host Federally Qualified Health Center Emergency Room Department of Health Residential Treatment Center Rural Locations Children Psychiatry

31. Florida’s Substitute Services Carry forward of the Prepaid Mental Health Plans Not designed for substance abuse prevention or treatment services Adds medical home dimensions to care Permitted but no plan has requested use

32. Substitute Services 1.Plan Request 2.AHCA Approval 3.Provider Contract Peer Services H0038 Peer Services Outreach H2015 Outreach Respite H006HE Respite In Home H2019HB In Home Partial Hospital 0912 Partial Hospital Family Training T1027 Family Training Therapeutic In Home H0046HK Therapeutic In Home Wrap Around H2022 Wrap Around

33. A Florida Strategy for Substitute Services Turn on Substitute Service Codes Redefine to clarify applications to substance abuse especially partial hospital, peer and outreach Add SBIRT at higher rate Allow innovations and flexibility with new definitions or codes

34. Healthy Behaviors Alcohol and Drug Screening and Treatment Annual Provider Training PCP screening on first visit, routine physicals, ER utilization patterns Provide alcohol or substance abuse recovery program Plan reports on activities to Florida Medicaid Residential Detox not a federally covered service

35. Healthy Behaviors Incentive Plans up to $50 Per Enrollee Smoking Cessation Medically directed weight loss Alcohol or substance abuse identification Identification of Pregnant WomenHealthBehaviorServices

36. Healthy Behaviors Manage incentive plan Sell smoking cessation or weight loss for current clients Propose alcohol or substance abuse screening and engagement service for PCP Outreach to pregnant women to engage in prenatal care Plan Demonstration Projects

37. MMA ADVOVACY INITIATIVES Behavioral Health Medical Loss Ratio Code Innovations for Behavioral Health Transparent data, bids, contracts, reports and provider manuals Mental Health Excellence Act Require that plans include CMHCs in network

38. Mental Health Excellence Act National Council for Behavioral Health Initiative Act of Congress on March 31, 2014 Improves Medicaid rate reimbursement 90% FMAP Creates certified community behavioral health clinics

39. Mental Health Excellence Act Provides $25m in state planning grants for 2 year pilot Eight states selected to participate for 2 year pilot Requires states to develop prospective payment system

40. Mental Health Excellence Act Publication of clinic criteria Sept. 1, 2015 Award of planning grants Jan. 1, 2016 Selection of participating states Sept. 1, 2017

41. Mental Health Excellence Act Clinic Certification Requirements 1.Staffing 2.Access 3.Care Coordination 4.Scope of Services 5.Quality 6.Nonprofit/Government

42. Mental Health Excellence Act

43. How Florida Gets Mental Health Excellence Florida providers prepare to meet Excellence Act certification Florida legislature authorizes AHCA to apply for planning grant Associations assist AHCA in developing planning grant application Advocate for Florida at Federal Level Better align MMA with Excellence Act Florida secures planning grant

44. Don’t Miss This! Thursday, August 7th - 1:30pm-3:00pm workshop Excellence in Mental Health Act: Where Do We Go From Here? Grand Cypress C Rebecca Farley National Council for Behavioral Healthcare

45. The Finish Line