1. Drug Medi-Cal Organized Delivery System Waiver

2. DMC Benefits Prior to ACA
Mandatory Population Only
Modalities
Outpatient Drug Free (ODF) - all mandatory populations
Narcotic Treatment Programs (NTP) - all mandatory populations
Residential (perinatal only in non-IMDs)
Intensive Outpatient Therapy (IOT) - perinatal only

3. ACA Expansion Increased Eligible Beneficiaries (Expanded Population)
CA chose to expand modalities
IOT (for Mandatory and Expanded Populations)
Residential (for Mandatory and Expanded Populations)

4. ACA Expansion Residential Services
Residential needed in the continuum of care
Restricted due to the Institute for Mental Disease (IMD) exclusion
Ninety percent of California’s residential bed capacity is considered an IMD
Clients in IMD’s restricted from all MediCal services
Without the DMC-ODS Waiver Pilot, California cannot provide residential services

5. Development of DMC-ODS
Conducted a SUD Needs Assessment
Program Integrity Issues
Physical and Behavioral Health Integration
Merging of Departments
Screening Brief Intervention and Referral Treatment in Managed Care (SBIRT)

6. Stakeholder Process
January DHCS began the stakeholder engagement process
April DHCS held three Waiver Advisory Group (WAG) meetings
July DHCS released draft Standard Terms and Conditions (STCs)

7. Stakeholder Process
Additional WAGs were held in July 2014, January 2015, Feb 2015 and March 2015
Participants: counties, provider associations, Alcohol and Other Drug counselor certifying organizations, managed care health plans, public interest advocates, and legislature
Meeting notes posted on the website

8. DMC Organized Delivery System Waiver
The goal is to improve Substance Use Disorder (SUD) services for California beneficiaries
Authority to select quality providers
Consumer-focused; use evidence based practices to improve program quality outcomes
Support coordination and integration across systems
1. As of November , DHCS is proud to report that over 270,864 people opted in using Express Lane Enrollment (ELE) and are now receiving Medi-Cal benefits.
2. DHCS conducted another mailing to approximately 380,000 individuals in October and November ,000 individuals are newly enrolled in CalFresh; therefore, could be newly eligible for ELE. The remaining 178,000 individuals are those who did not opt in from the first ELE mailing in February Health Care Options is doing further outreach by phone to those individuals who did not respond to the letters sent in 2014.

9. DMC Organized Delivery System Waiver
Reduce emergency rooms and hospital inpatient visits
Ensure access to SUD services
Increase program oversight and integrity
Provide availability of all SUD services
Place client in the least restrictive level of care
Total application portal transactions submitted as of 11/08/14: 206, 954
Individuals approved for PE: 157,279
Individuals denied for PE: 32,162
(The denied amount includes multiple portal submission attempts.)
Three main reasons individuals are denied for PE:
Over income limit
Found eligible for Medi-Cal
Has coverage through Covered California
Total web portal transaction issues: 17, 513
Pending Caseload:
Assumptions: Contains Unique, De-Duplicated Medi-Cal Applicants in Pending Status
Counted as month of submission
Excludes cases under 45 days
"Of the pending, the following additional reductions may be realized:
1. Approximately 20,000 (under age 19) with pending eligibility via the county access using presumptive eligibility.
2. Minimally 40,000 to be administratively denied."
Source: CalHEERS

10. DMC Organized Delivery System Waiver
DMC Services
SPA ( Non-Waiver
Opt-in Waiver
Outpatient/Intensive Outpatient X
NTP
Residential
X (one level)
Withdrawal Management
Recovery Services
Case Management
Physician Consultation
Additional MAT
X (optional)

11. General Provisions
Amendment to Bridge to Reform and folded into MediCal Waiver
Pilot for 5.5 years
Does not require a change in Statute or regulations
Counties choose to opt-in
53 of 58 counties expressed an interest

12. Early Intervention Services
SBIRT (screening, brief intervention and referral to treatment) American Society of Addiction Medicine (ASAM) Level 0.5
Provided by non-DMC providers to beneficiaries at risk of SUD (through FFS system)
Referrals by managed care providers or plans to DMC-ODS will be governed by the Memorandum of Understanding

13. Outpatient
ASAM Level 1
Individual and group counseling up to 9 hours a week for adults
Determined by a Medical Director or Licensed Practitioner of the Healing Arts (LPHA)
Services can be provided in-person, by telephone or by telehealth (except group)
Addition of family therapy

14. Intensive Outpatient ASAM Level 2.1
Minimum of nine hours with a maximum of 19 hours a week for adults
Determined by a Medical Director or LPHA
Services can be provided in-person, by telephone or by telehealth (except group)
Addition of family therapy

15. Partial Hospitalization
ASAM Level 2.5
20 or more hours of clinically intensive programming per week
Providing this level of service is optional for participating counties

16. Residential
5 Levels of Residential Based on ASAM (Levels 3.1, 3.3, 3.5, 3.7 and 4.0)
One level required for DMC-ODS
No bed capacity limit
The length of residential services range from 1 to 90 days with a 90-day maximum for adults

17. Residential
Medical necessity can authorize a one-time extension of up to 30 days on an annual basis
Only two non-continuous 90-day regimens will be authorized in a one-year period
Perinatal clients may receive a longer length of stay based on medical necessity
CDRH and Acute Free Standing Psych paid through the FFS system

18. Withdrawal Management
(Levels 1, 2, 3.2, 3.7 and 4 in ASAM)
Determined by a Medical Director or LPHA
Monitored during detoxification
IMD expenditure approval for Chemical Dependency Recovery Hospitals and Free Standing Psychiatric Hospitals (paid through FFS system)

19. Opioid (Narcotic) Treatment Program
ASAM OTP Level 1
Required service in all opt-in counties
Adding buprenorphine, disulfiram and naloxone in NTP settings
Minimum fifty minutes of counseling sessions up to 200 minutes per calendar month or more with medical necessity

20. Additional Medication Assisted Treatment
The goal of the DMC-ODS for Medication Assisted Treatment (MAT) is to open up options for patients to receive MAT by requiring MAT services in all opt-in counties, educate counties on the various options pertaining to MAT and provide counties with technical assistance to implement any new services

21. Additional Medication Assisted Treatment

22. Recovery Services
May access recovery services after completing the course of treatment, if triggered, if relapsed or as a preventative measure to prevent relapse
Provided face-to-face, by telephone, or by telehealth with the beneficiary and may be provided anywhere in the community

23. Case Management Counties will coordinate case management services
Services can be provided in various locations
Coordinate with Mental and Physical Health
Provided face-to-face, by telephone, or by telehealth

24. Physician Consultation Services
Physician consultation services with addiction medicine physicians, addiction psychiatrists or clinical pharmacists
Designed to assist DMC physicians with treatment plans for DMC-ODS beneficiaries
Medication selection, dosing, side effect management, adherence, drug-to-drug interactions, or level of care considerations

25. Criminal Justice System
Additional Lengths of Stay (up to 6 months residential; 3 months Federal Financial Participation (FFP) with a one-time 30-day extension)
If longer lengths, other county identified funds can be used

26. Provider Specifications
Addition of LPHAs: Physician, Nurse Practitioners, Physician Assistants, Registered Nurses, Registered Pharmacists, Licensed Clinical Psychologist (LCP), Licensed Clinical Social Worker (LCSW), Licensed Professional Clinical Counselor (LPCC), and Licensed Marriage and Family Therapist (LMFT)

27. County Responsibilities
Selective Provider Contracting
Access to Services
Medication Assisted Treatment
Contracting Requirements
Provider Appeals Process
Residential Authorization

28. County Responsibilities
County Implementation Plan
County Fiscal Plan
Two Evidence Based Practices (motivational interviewing, Cognitive-Behavioral Therapy, Relapse Prevention, Trauma-Informed Treatment, Psycho-Education)

29. County Responsibilities
MOU with all managed care providers
Comprehensive Screening
Beneficiary Engagement
Shared Plan Development/Treatment Planning
Case Management Activities
Dispute Resolution
Care Coordination/Referral Tracking
Navigation Support

30. County Responsibilities
Beneficiary Access Number
Care Coordination with Mental and Physical Health Services
State/County Contract

31. State Responsibilities
Integration Plan
Innovation Accelerator Program
ASAM Designation for Residential facilities
Oversee Provider Appeals Process
Monitoring Plan
Timely Access
Program Integrity
Triennial Reviews

32. Quality Improvement Counties must have: QI Plan QI Committee
Review Accessibility of Services Data
Utilization Management Program
Participate in Annual External Quality Reviews

33. Financing
Rates
Counties will negotiate provider rates by modality (except for NTP Services which will remain set by DHCS)
The state will have final approval of the rates
If the state rejects the rates, the county can resubmit revised rate

34. Financing Realignment
Counties receive realignment funds derived from sales tax revenues deposited into their Behavioral Health Subaccount to pay for a portion of DMC treatment services 

35. Financing
The cost of all DMC Waiver services will be shared among the federal government, State government and the counties
The Federal government will continue to pay FFP for the existing population (mandatory) at the 50% rate (including residential services)

36. Financing
The Federal government will pay FFP for the expansion population at the applicable enhanced rate (including residential), currently 100%, decreasing to 95% in 2017, and so on until reaching 90% in 2020 and beyond
Sharing Ratio is county specific

37. Financing
The non-federal share will be split between the State/County based on a county-specific State/County sharing ratio
Quality Assurance Activities will be reimbursed at 75% FFP

38. Financing
The sharing ratio will apply to outpatient, intensive outpatient, NTPs (including buprenorphine and disulfiram), recovery services, case management, physician consultation, residential, quality assurance activities, and county administration services

39. Evaluation
University of California, Los Angeles, (UCLA) Integrated Substance Abuse Programs will conduct the evaluation
Four key areas of access, quality, cost, and integration and coordination of care

40. Federal 438 Requirements
Counties held to all federal 42 CFR 438 requirements (quality assurance, beneficiary protections, access)
External Quality Review requirements must be phased in within 12 months of having an approved implementation plan

41. Tribal Delivery System
DHCS will consult with the tribes and the four tribal 638/urban programs after approval of the amendment
Phase 5 implementation will focus on the tribal system after the amendment has been approved by CMS

42. DMC-ODS Waiver Implementation
Regional Implementation
Phase I – Bay Area (May-August 2015)
Phase II – Southern California
Phase III – Central Valley
Phase IV – Northern California
Phase V – Tribal Delivery System

43. DMC-ODS Waiver Implementation
Next Waiver Advisory Group Meeting
Between Phase One and Two
County Regional Waiver Meetings
Phase One meeting: May 2015
Phase Two meeting: October 2015

44. DMC-ODS Waiver Implementation
Technical Assistance from DHCS
State Implementation Plan
Designing a Training Plan
DHCS Substance Use Disorders Statewide Conference
“Organizing the SUD Delivery System”
October 26-27, 2015

45. Implementation Responsibilities
PTRS Division
IT Changes to Short-Doyle
State/County Contract
DMC Monitoring Protocol
Provider Enrollment Division
DMC Certification

46. Implementation Responsibilities
SUD Compliance Division
County and Fiscal Implementation Plans
Provider Appeals Process
ASAM Designation for Residential
External Quality Review Organization
Expansion of MAT
Coordinate WAGs and EAGs

47. Implementation Responsibilities
SUD Compliance Division
UCLA Evaluation
Training Plan and Contract
Technical Assistance
County Liaisons
Integration Plan
CMS- Innovation Accelerator Program

48. DMC-ODS Waiver Implementation
DHCS DMC-ODS Website