New York State Behavioral Health Transition to Managed Care Regional Planning Consortium

2 June 2016 Agenda Introductions Overview of Medicaid Managed Care transition of behavioral health services New York State Vision for behavioral health transformation Consumer and Provider Protections Lessons Learned from NYC Implementation Regional Planning Consortiums Questions and Discussion

3 June 2016 Understanding Changes to Medicaid Behavioral Health Care in New York

June What are the Goals for the Medicaid Managed Care Changes? Better Health Better Care Greater Access Lower Costs

5 Key challenges for NYS reform Large system with wide range of provider services and expertise Heavy reliance on fee-for-service (FFS) payment methodology that incentivizes volume Lack of accountability for high-need patients Few incentives to support integration both within behavioral health (inpatient- ambulatory-rehabilitation) and across behavioral/general medical health care Limited capacity to share information within and between the behavioral health and other systems (managed care organizations, criminal and juvenile justice, homeless, systems) June 2016

6 BHO Phase I: High rates of failed care transitions BHO Phase I readmission rates for Adult Mental Health and SUD discharges, CY 2012 June 2016

7 BHO Phase I: Rates of follow-up after hospitalization for mental illness Attended initial outpatient Within 7 days Within 30 days National Medicaid HMO, %61% NYS Medicaid HMO, %78% NYS Medicaid Fee-For-Service, %47% June 2016

8 1.Reduce unnecessary inpatient use 2.Improve care transitions 3.Crisis Services Programs become the front door to acute care 4.Ambulatory clinic re-design 5.Implement new recovery-oriented services 6.Promote integration of behavioral and general medical health services 7.Establish cross-agency collaborations around vulnerable populations 8.Shift payment models to reward value over volume OMH/OASAS Transformation Agenda June 2016

9 Mental Health and Substance Use Services (Behavioral Health) will be managed by: Managed Care Organizations (MCO) meeting rigorous standards (perhaps in partnership with a Behavioral Health Organization (BHO)) All Plans MUST qualify to manage newly carved in behavioral health services and populations Plans can meet State standards internally or contract with a BHO to meet State standards Health and Recovery Plans (HARPs) for adults with significant behavioral health needs MCOs may choose to apply to operate a HARP product with expanded benefits HIV SNPs will include HARP benefits for eligible members (NYC only) What is Changing? June 2016

10 Existing State Plan Benefits Moving into Medicaid Managed Care: Inpatient Psychiatric Services* Mental Health Clinic* Partial Hospitalization Personalized Recovery Oriented Services (PROS) Assertive Community Treatment (ACT) Continuing Day Treatment (CDT) Comprehensive Psychiatric Emergency Program (CPEP) Intensive Psychiatric Rehabilitation Treatment (IPRT) Rehabilitation Services for Residents of Community Residences (CRs)-deferred until further notice 1115 Demonstration Services Only: Crisis Intervention Other Licensed Mental Health Practitioner Services (off-site services out of mental health clinic) *already in benefit for non-SSI populations Adult Behavioral Health Transition to Managed Care: Mental Health Services June 2016

11 Currently in Medicaid Managed Care: Detox Services Inpatient Substance Use Disorder Treatment Moving Into Medicaid Managed Care: Opioid Outpatient Treatment Outpatient Clinic Residential Treatment Services Adult Behavioral Health Transition to Managed Care: Substance Use Disorders June 2016

12 Residential Redesign - Plans allowed to purchase medical/clinical services in OASAS residential programs Three phases (captures OASAS Intensive Residential, Community Residential, Supportive Living and Medically Monitored Detox: Stabilization – Introduction of medical/clinical staff. Individual will receive medically-directed care to treat acute problems and adjust early to recovery. Rehabilitation – Individual will learn to manage recovery within the safety of the program. Re-integration – Individual will further develop recovery skills and begin to re-integrate into the community. Clinic to Rehab - Allows for provision of community based substance use disorder services Adult Behavioral Health Transition to Managed Care: New OASAS SPA Services June 1, 2016

June Health and Recovery Plans (HARPs)

June Health and Recovery Plans (HARPs) New type of Medicaid Managed Care Plan Designed for people with serious mental health conditions and substance use disorders Covers all benefits provided by Medicaid Managed Care Plans, including expanded behavioral health benefits Also provides additional specialty services to help people live better, go to school, work and be part of the community

June How are HARPs different than other Medicaid Managed Care Plans? HARPs specialize in serving people with severe behavioral health conditions HARPs cover additional services called Adult Behavioral Health Home and Community Based Services (BH HCBS) Some HARP enrollees will be eligible for Adult BH HCBS A Care Manager, providers and Plans will work together to assist HARP members

June Adult Behavioral Health Home and Community Based Services (BH HCBS)

June Adult Behavioral Health Home and Community Based Services (BH HCBS) - GOALS Help people improve their quality of life, including getting and keeping jobs, getting into school and graduating, managing stress, and living independently Help people meet their recovery and life goals Only available to people in HARP or people in an HIV SNP who are HARP eligible

June Adult Behavioral Health Home and Community Based Services (BH HCBS) Maintain Housing. Live Independently. Psychosocial Rehabilitation Community Psychiatric Support and Treatment Habilitation Non-Medical Transportation for needed community services Return to School. Find a Job. Education Support Services Pre-Vocational Services Transitional Employment Intensive Supported Employment Ongoing Supported Employment Manage Stress. Prevent Crises. Short-Term Crisis Respite Intensive Crisis Respite Get Help from People who Have Been There and Other Significant Supporters Peer Support Services Family Support and Training

June How do I Access Adult BH HCBS? HARP enrollees must have an assessment to determine need for BH HCBS Assessment shows if people are eligible for BH HCBS and which BH HCBS they need To get BH HCBS, a Health Home Care Manager must complete the assessment Care Managers also help people eligible for BH HCBS to make a Plan of Care A Plan of Care identifies life goals and the services needed to help people reach their goals The Plan of Care MUST focus on what the person needs and wants

June Who is Affected by these Medicaid Changes? Mainstream Managed Care People 21+ enrolled in Medicaid Managed Care No duals (Medicaid/Medicare enrollees) Not participating or enrolled in a program with the Office for People with Developmental Disabilities (OPWDD) HARP SMI/SUD diagnoses Historical use of certain services Identified by NYS using Medicaid data

June When are these Changes Happening? October 1, 2015 NYC – Adults (Live) BH HCBS services January 1, 2016 (Live) July 1, 2016 ROS – Adults BH HCBS services October 1, 2016 July 1, NYC and Long Island – Children January 1, 2018 – ROS - Children

June What Plans will be Managing these Services?

June How are Consumers and Providers Protected During the Transition?

June Protections Several key provisions incorporated into the Medicaid Managed Care Model contract: Ensuring Medicaid Managed Care plans establish adequate behavioral health provider networks; Promoting financial stability through payment and claiming requirements; and Supporting access to and removing barriers to mental health treatment and recovery services.

June Contract Requirements BH Self-referrals - Unlimited self-referrals for mental health and substance use disorder assessments from participating mental health clinic providers and substance use providers. Ambulatory Patient Groups (APG)/Fee for Service Rate Mandate - Government rates for 24 months from effective date of BH inclusion. Continuity of Care Requirements - 2 year continuity of care language. Plans must permit enrollees to continue receiving services from their current provider(s) for “Continuous Behavioral Health Episodes of Care.” 90 day transition - Prohibits utilization review for 90 days from the effective date of the Behavioral Health benefit inclusion.

June Contract Requirements and Statute BH Pharmacy Access - pharmacy services include immediate access / no prior authorization language for BH prescribed drugs – generally 72 hour supply; and 7 day supply for prescribed drug or medication associated with the management of opioid withdrawal and/or stabilization. Primary Care in OMH Programs /PCPs - The enrollee must choose or be assigned a specific provider or provider team within the clinic to serve as his/her PCP. Contracts for existing providers - Plans must offer to contract with any OMH or OASAS providers with five or more active plan members.

June Contract Requirements and Statute All Products Clause-Plans are prohibited from requiring BH providers to participate in non-Medicaid lines of business Smoking Cessation-members with one or more substance use disorders or mental illness(s) may be allowed to access unlimited courses of smoking cessation products Long Acting Injectables- Plans may not require prior authorization of typical long acting antipsychotics

28 Lessons Learned from NYC Implementation June 1, 2016

June 2016 Monitoring NYC Implementation Service Delivery OMH and OASAS have developed templates to track behavioral health service utilization during the transition period MCOs will submit monthly report to the State on all denials of continuing care for inpatient behavioral health services based on medical necessity. MCOs will submit quarterly reports that include monthly BH ambulatory service denials aggregated at the MCO level by service. Claims Paid, Pended, and Denied Comparisons against previous year FFS data Expenditures: Reports to track timeliness of payment BH and HARP Medical Loss Ratio (MLR) Mainstream Plans will have a BH Medical Loss Requirement HARP will have an integrated MLR 30

June 2016 BH Managed Care NYC Roll Out: Initial Lessons Learned Claims systems and needed edits for Behavioral Health transitions Unlicensed providers issue EMR Billing System Role of the clearinghouse in getting a claim to the MCO Use the billing manual [link] Issues related to member services call routing Building a robust communication process with Plans, Providers and State Complexities related to Provider Contracting and Credentialing Providers need to ensure they are connected to larger networks in preparation for VBP. 31

June 2016 Contracting, Credentialing and Billing Timeline* 32 Contracting and Credentialing 6 months prior to go-live Claims Testing 3 months prior to go-live Billing Go Live *Timeline relies on estimation of when information from state and designated MCOs are finalized and available.

32 June 2016 Regional Planning Consortiums

June Regional Planning Consortiums 11 Regional Planning Consortiums created to inform the State about needs and issues in the local region. Managed Care Organizations (MCO) are required to participate in all Regional Planning Consortiums for their coverage area All RPCs must include participation from: consumers and their families State and local government Providers, including Health Homes RPCs will inform the State and MCOs about Training needs Network issues Unmet service needs

June Regional Planning Consortiums The RPCs will be the central point of all stakeholders to share information, collaborate and problem-solve issues surrounding the transition of the behavioral health service system from Medicaid fee-for-service to Medicaid managed care and issues that arise from the other NYS behavioral health transformation initiatives which impact the transition to Medicaid managed care. The RPCs will convene a multi-stakeholder behavioral health advisory body. This body will include: consumers, including family and youth, LGUs, adult and child behavioral health services and housing providers, managed care organizations, hospital, primary care providers, county Social Services and Public Health Departments and representatives from the PPSs and PHIPs.

Comments or questions If you have comments, questions, concerns regarding the Behavioral Health Transition please contact the following mailboxes: OMH: OASAS: Practice Innovation and Care Management (PICM) MailboxPractice Innovation and Care Management (PICM) Mailbox DOH: al_health/consumer_info/index.htm al_health/consumer_info/index.htm Health Homes: medicaid_health_homes/ HealthHome.action

Other Resources RPC Director: James Button DOH complaints: are/complaints/index.htm are/complaints/index.htm or CLMHD web site: