CCBHC Prospective Payment System (PPS) Technical Assistance Session 7 Webinar: Demonstration Claiming March 24, :30-4:00 pm ET

I.Welcome II.Demonstration Claiming a.Webinar Goal b.FMAP available for demonstration services c.Claiming administrative costs d.Funding the non-federal share of payment e.Reporting in Medicaid Budget and Expenditures System (MBES) f.Paying for services provided to dually enrolled beneficiaries g.Paying a dually certified clinic h.Health Homes and CCBBHCs III.Questions IV.PPS Webinar Schedule Webinar Agenda 2

This webinar is meant to provide information about factors that affect the amount a state may claim as a demonstration expenditure and MBES reporting. Webinar Goal 3

FMAP Available for Demonstration Services PAMA Section 223(d)(5) matching rates for Demonstration expenditures: 5 ServiceRate MA beneficiaries enrolled in the New Adult Group defined as “newly eligible” at 1905(y)(2)(A) of the Social Security Act Matched at the newly eligible FMAP rate* 95% for calendar quarters in % for calendar quarters in % for calendar quarters in % for calendar quarters in 2020 and beyond Indian Health Service or Tribal facilities furnished to American Indian and Alaskan Natives Matched at 100% Services for targeted low income children in CHIP program (note: also applied against the state CHIP allotment) Matched at enhanced FMAP in section 2105(b) with 23 percentage point increase 10/1/15 - 9/30/19 unless state elects not to claim All other service expendituresMatched at the CHIP enhanced FMAP rate without 23 percentage point increase *under paragraph (1) of section 1905(y) of Social Security Act (42 U.S.C. 1396(y))

FMAP Available for Demonstration Services (continued) Under the Demonstration, states may claim: – Enhanced FMAP and do not need Medicaid state plan authority to implement payment for CCBHC services – Only expenditures for demonstration services provided to Medicaid beneficiaries – Administrative expenditures that support the development and implementation of the Demonstration States cannot receive enhanced FMAP when the Demonstration ends; to extent applicable, newly eligible FMAP and the IHS/Tribal FMAP would continue to apply States not selected for the Demonstration are not eligible for enhanced FMAP 4

Claiming Administrative Costs Rules for claiming administrative costs – Section 1903 of the Social Security Act (Act) provides for variable federal matching rates to states for administrative expenditures claimed under Medicaid; however, most administrative costs are reimbursable at 50 percent federal financial participation (FFP). – In accordance with section 1903(a)(7) of the Act activities must be “found necessary by the Secretary for the proper and efficient administration of the plan.” 6

Claiming Administrative Costs (continued) 7 Examples of Acceptable Administrative Claiming Costs Conducting outreach for Demonstration services Providing referral assistance for Demonstration services Providing specific training for Demonstration-related services Examples of Unacceptable Administrative Claiming Costs Funding for a portion of general public health initiatives that are made available to all persons Overhead costs of operating a provider facility Costs related to a call center for which beneficiaries consult with nurses on appropriate action to take if a medical situation occurs.

Funding the Non-Federal Share of Payment Federal financial participation (FFP) is available for demonstration services only when there is a corresponding state expenditures. Federal payment is based on statutorily-defined percentages of total computable expenditures. Slide 4 shows all service FMAPs applicable under this demonstration. When applying to participate in this demonstration states will explain the source(s) of the non federal share of payment. 8

Funding the Non-Federal Share of Payment Possible sources of the non- federal share of payment for this demonstration General fund revenue appropriations to the Medicaid agency Health care related taxes* Intergovernmental transfers (IGT) *See slide 10 for more information about taxes and slide 11 for a discussion of Certified Public Expenditures. 9

Funding the Non-Federal Share of Payment – Provider Taxes Q1: Can provider taxes be used to fund the non- federal share of demonstration payment? A1: In accordance with 42 CFR , a provider tax may be used to the extent: (1) it is imposed on a permissible class of services; (2) applies to all providers in the class; (3) applies uniformly to all providers in the class; and (4) contains no hold harmless arrangement in which taxes are returned directly or indirectly. A CCBHC in its entirety is not a permissible provider class. Although individual services may be eligible for a provider assessment if the state can identify the amount of payment within the PPS attributable to individual services. Q2: If a state wishes to use a provider tax for this demonstration what next steps should it take? A2: The state should contact its CMS Regional Office and request an evaluation of its tax proposal. 10

Funding the Non-Federal Share of Payment – CPEs Q1: What is a CPE and when can a state utilize it to fund the non federal share of payment for demonstration services? A1: A CPE is a mechanism by which a governmental entity (e.g. city, county or state) recognizes and certifies its total computable (federal plus non federal) cost incurred to provide a Medicaid service. Cost must be identified at the level of the entity whose cost is being certified. Use of a CPE requires recognition of actual cost while PPS is expressed as a rate that reimburses the expected cost of care. Due to this difference a state may not use CPEs to fund the non federal share of PPS payment rates under the Demonstration. 11

MBES Reporting All Medicaid expenditures are reported by states to CMS using the Medicaid Budget and Expenditures System (MBES). CMS is modifying MBES to allow states to report demonstration expenditures according to the various FMAPs for payments made fee for service and through managed care. States will be able to claim expenditures starting with a 1/1/17 date of service. 12

MBES Reporting CMS is adding the line “Certified Community Behavioral Health Clinic Payments” to various MBES worksheets. CMS Regional MBES contacts will support states in properly reporting demonstration expenditures. 13 Example: 64.9VIII

MBES and CMS-37 Reporting New 64.9 lines will be added to the 64.9 “series” – 64.9, 64.9P – 64.9WAIV. 64.9PWAIV – 64.9VIII, 64.9PVIII – 64.9VIIIWAIV, 64.9VIIIPWAIV – 64.9T, 64.9TP New lines will be added to the MCHIP forms – 64.21, 64.21P, 64.21UP New lines will be added to the budget forms – 37.3, 37.3I *Must claim demonstration on the correct lines to receive the increased FMAP *Increased FMAP is automatically calculated within the new lines after entering in total computable expenditures *New lines will be available prior to filing FFY 2017 Q2 CMS-37 14

New Line NumberTitleClaim Type 2c Certified Community Behavioral Health Clinic Payments Fee for Service 18A5 Certified Community Behavioral Health Clinic Payments Managed Care Organization (MCO) 18B1e Certified Community Behavioral Health Clinic Payments Prepaid Ambulatory Health Plans (PAHP) 18B2e Certified Community Behavioral Health Clinic Payments Prepaid Inpatient Health Plans (PIHP) 3B* Certified Community Behavioral Health Clinic Payments Fee For Service and Managed Care MBES Reporting – New Lines Added 15

Payment for Services Provided to Dual Beneficiaries The PAMA at 223(d)(2)(B)(v) requires the state to pay the PPS rate. There are various types of dually eligible beneficiaries, which has direct bearing on cost sharing requirements imposed on states. There are three types of dual beneficiaries—Qualifying Individuals (QI), Specified Low-Income Medicare Beneficiaries (SLMB), and Qualified Disabled and Working Individuals (QDWI)—for which Medicaid does not cost share for services. Rather, MA cost shares for Medicare Part B premiums for the QIs and SLMBs and for Medicare Part A premiums for QDWIs. This means Medicaid is not required to pay up to PPS for these three types of duals. Payment for services to all other types of dual beneficiaries requires payment up to PPS. 16

Payment to Dually Certified Clinics A CCBHC also may participate in the Medicaid program and receive payment authorized through the Medicaid state plan as a: FQHC Health Home Clinic Services Provider (provider of services not considered CCBHC services ) Tribal Facilities 17

Payment to Dually Certified Clinics (continued) A clinic that is dually certified as a CCBHC and provides clinic services in the Medicaid program should be paid the CCBHC PPS rate whenever Demonstration-covered services are provided. The state should continue to pay the clinic services rate authorized through the Medicaid state plan whenever a non-CCBHC service is delivered. A clinic is eligible for payment of the CCBHC PPS and the clinic services rate if non overlapping services are provided. States will follow the established process for reporting expenditures for Medicaid clinic services using MBES. 18

Payment to Dually Certified Clinics (continued) Payment Principles The statute implementing the demonstration does not require states to dismantle existing delivery systems or payment rates. States have flexibility in planning their demonstrations and their applications should include details about key components of their CCBHC proposal such as non-duplication of payment and the incorporation of the expected costs of the nine demonstration services into the PPS rate. Different rates for different eligibility groups are only permissible for payment made through CC – PPS2. 19

Health Homes and CCBHCs Q1: How should the state pay certified clinics that also are Health Home (HH) providers? A1: The state should pay the CCBHC PPS to a certified clinic rate to the extent a demonstration service has been provided. Q2: How should the state construct the CCBHC PPS rate when a clinic is both a certified clinic and HH provider? A2: The CCBHC PPS should reflect the cost of all nine demonstration services but may be adjusted to reflect reimbursement of the portion of cost also reimbursed under another Medicaid benefit category, such as Health Homes. 20

Webinar Topic Date Quality Bonus Payments Thu 4/7/16, 2:30-4pm ET Managed Care PaymentThu 4/21/16, 2:30-4pm ET Open TA SessionsThu 5/19 & 6/16, 2:30-4pm ET PPS Webinar Topics & Schedule *Topics and dates are subject to change 21

Questions 22

Mailboxes – CMS mailbox for PPS guidance-related questions: – CMS mailbox for Quality Based Payment-related questions: 223 PPS TA SharePoint Site Link – Crosswalk template for State developed cost reports Q&As posted at the 223 Landing Page on Medicaid.gov 223 Landing Page on Medicaid.gov Collaboration Tools 23