Children’s Medicaid Redesign and Value Based Payments (VBP)

Children’s Medicaid Redesign and Value Based Payments (VBP)
New York State Coalition for Children’s Behavioral Health Presentation by Lana I. Earle Deputy Director, Office of Health Insurance Programs November 29, 2016

November 2016 2 Key Concepts on the Road to Value Based Payments – Bringing it all Together Medicaid Redesign Team (MRT) – Children’s Medicaid Redesign Plan / Behavioral Health and Health Transition to Managed Care Delivery System Reform Incentive Payment Program (DSRIP) Value Based Payments (VBP)

Creation of Medicaid Redesign Team
November 2016 3 Creation of Medicaid Redesign Team In 2011, Governor Cuomo created the Medicaid Redesign Team (MRT) Made up of 27 stakeholders representing every sector of healthcare delivery system Developed a series of recommendations to lower immediate spending and propose reforms Closely tied to implementation of ACA in NYS The MRT developed a multi-year action plan – that Plan includes: The Children’s Medicaid Redesign Plan 1115 Waiver that includes: Delivery System Reform Incentive Payment Program (DSRIP) Value Based Payments The Goals of MRT: Transform the State’s Health Care System, Bend the Medicaid Cost Curve, Assure access to quality care for all Medicaid members, Create a financially sustainable safety net infrastructure

November 2016 Children’s Medicaid Redesign Plan – MRT Vision for Children’s Transformation Keep children on their developmental trajectory Identify needs early and intervene Focus on recovery and building resilience Prevent escalation and longer term need for higher end services Maintain child at home with support and services Maintain the child in the community in least restrictive settings Maintain accountability for improved outcomes and delivery of quality care

Transforming System from Today to the Vision
November 2016 5 Transforming System from Today to the Vision Today Care Coordination is limited to six 1915c Waiver Programs and OMH TCM Program (12,000 kids) – no Health Home (Coming Soon! – December 8, 2016) Current state plan services Limited array of Home and Community Based Services (HCBS) available only to 1915c Waiver - children services depend on and vary by waiver Behavioral health and physical health services are not integrated Care planning is not integrated Transitional care across children’s system is lacking

Transforming System from Today to the Vision
November 2016 6 Transforming System from Today to the Vision Tomorrow Full Implementation of Children’s Design December 8, 2016 Health Home care management for children with two or more chronic conditions, serious emotional disturbance (SED), complex trauma, HIV Other care management for non-HH eligibles (e.g., Managed Care Plans, PCMH) Current state plan services Six new state plan services Integrate and transition behavioral health benefits to managed care Transition foster care per diem population to managed care Expanded array of 12 HCBS based on target, risk, and functional criteria Foster transitional care and continuity of care across children serving systems (education, child welfare, juvenile justice) Shift focus to quality, monitoring, and tracking and reward quality outcomes (value based payments) New investments in new and expanded services

Timeline for Children’s MRT Health and Behavioral Health Transition
November 2016 Timeline for Children’s MRT Health and Behavioral Health Transition Revised Timeline SPA Other Licensed Practitioners (OLP) - FFS (1 of 6 new SPA Services) 3/1/17 SPA Rehabilitation Services under Managed Care and FFS (Crisis Intervention, CPST, Family and Peer Supports, PSR – remaining 5 of 6 new SPA Services) SPA Other Licensed Practitioners under Managed Care and FFS 10/1/17 Downstate 1/1/18 Upstate NYC, Nassau, Suffolk, Westchester HCBS benefit array 1915(c)Waiver Care Management to Health Home BH Benefits Transition to Managed Care 10/1/17 Rest of State 1/1/18 LON Community Eligible – begin to receive HCBS benefits 7/1/18 LON Family of One – expansion group begins eligibility & access 1/1/19 Foster Care Population Transition to Managed Care (Accommodates Legislation and Licensing VFCA Required for MC Transition Under Corporate Practice of Medicine)

November 2016 DSRIP Objectives are Aligned with the Objectives of Health Home and Children’s MRT Transformation and Redesign Goal: Reduce avoidable hospital use – Emergency Department and Inpatient – by 25% over 5+ years of DSRIP Remove Silos Develop Integrated Delivery Systems Enhance Primary Care and Community-based Services Integrate Behavioral Health and Primary Care DSRIP was built on the CMS and State goals in the Triple Aim: Better care Better health Lower costs DSRIP has projects that seek to promote healthy women, infants, and children, but does not have an exclusive pediatric or child-focused project However, its holistic and integrated approach to healthcare transformation is set to have a positive effect on children’s health

November 2016 Performing Provider Systems (PPSs) are networks of providers that collaborate to implement DSRIP projects Assessing community healthcare needs based on multi-stakeholder input and objective data Implementing a DSRIP Project Plan based upon the needs assessment in alignment with DSRIP strategies Meeting and reporting on DSRIP Project Plan process and outcome milestones PPSs were required to include providers from the entire care continuum Hospitals Health Homes (for Children too!) Social Service Departments and Local Government Units Skilled Nursing Facilities Clinics & Federally Qualified Health Centers Behavioral Health Providers Home Care Agencies Physicians/Practitioners Other Key Stakeholders

DSRIP Project Organization
November 2016 PPS DSRIP Projects that Impact Children’s Healthcare DSRIP Project Organization Domain 2: System Transformation Domain 4: Population Health Domain 3: Clinical Improvement Domain 1: Organizational Components 3.a.i: Integration of primary care services and behavioral health 3.a.ii: Behavioral health community crisis stabilization services 3.d.ii: Expansion of asthma home-based self-management programs 3.d.iii: Evidence based medicine guidelines for asthma treatment 3.f.i: Increase support programs for maternal & child health 4.a.i: Promote mental, emotional, and behavioral well-being in communities 4.a.iii: Strengthen mental health and substance use infrastructure across systems 4.d.i: Reduce premature births Accessed 9 May 2016. Source: New York State DSRIP Project Toolkit. NYSDOH DSRIP Website.

DSRIP Will Have a Positive Impact on Children’s Health Outcomes
November 2016 DSRIP Will Have a Positive Impact on Children’s Health Outcomes Engagement Care managed by a coordinated set of integrated providers Value to the child, the family, and the healthcare system = Child in Medicaid with a chronic health condition After DSRIP Delivery Outcome Intermittent care provided by separate providers, as necessary Unnecessary ER visits & hospitalizations in childhood Unnecessary ER visits & hospitalizations throughout adulthood Unnecessary strain on the child, the family, and the healthcare system Today Preventive healthcare provides the resources the child requires Integrated care follows through adolescence into adulthood

November 2016 Sustaining the Objectives of DSRIP with Value Based Payment Reform: Delivery Reform and Payment Reform are Two Sides of the Same Coin A thorough transformation of the delivery system can only become and remain successful when the payment system is transformed as well Many of NYS system’s problems (fragmentation, high re-admission rates) are rooted in how the State pays for services Fee-for-Service (FFS) pays for inputs rather than outcome; an avoidable readmission is rewarded more than a successful transition to integrated home care Current payment systems do not adequately incentivize prevention, coordination, or integration Financial and regulatory incentives drive… a delivery system which realizes… cost efficiency and quality outcomes: value

The Old World: Fee for Service; Each in its Own Silo
November 2016 13 The Old World: Fee for Service; Each in its Own Silo There is no incentive for coordination or integration across the continuum of care Much Value is destroyed along the way: Quality of patient care & patient experience Avoidable costs due to lack of coordination, rework, including avoidable hospital use Avoidable complications, also leading to avoidable hospital use PCPs Rx Behavioral Health Professionals Medical Equipment and Appliances Laboratory Services Imaging Services Home care Specialty docs Hospital / Clinic outpatient services Inpatient services Home Care Physiotherapy Nursing home care Facilities for the disabled Mental Health Facilities

Reforming the Payment System and Moving from Volume to Value
November 2016 Reforming the Payment System and Moving from Volume to Value Value Based Payments (VBP) An approach to Medicaid reimbursement that rewards value over volume An approach to incentivize providers through shared savings and financial risk A method to directly tie payment to providers with quality of care and health outcomes A component of DSRIP that is key to the sustainability of the program VBP arrangements are not intended primarily to save money for the State, but to allow providers to increase their margins by realizing value. Source: _Draft - NYSRA Annual Summit Presentation(f2).pptx HW: Confirmed. Volume Value Current State Future State Source: New York State Department of Health Medicaid Redesign Team. A Path Towards Value Based Payment, New York State Roadmap for Medicaid Payment Reform. NYSDOH DSRIP Website. Published March 2016.

Different Types of VBP Arrangements
November 2016 Different Types of VBP Arrangements Types Total Care for General Population (TCGP) Integrated Primary Care (IPC) Care Bundles Special Need Populations Definition Party(ies) contracted with the MCO assumes responsibility for the total care of its attributed population Patient Centered Medical Home or Advanced Primary Care, includes: Care management Practice transformation Savings from downstream costs Chronic Bundle (includes 14 chronic conditions related to physical and behavioral health related) Episodes in which all costs related to the episode across the care continuum are measured Maternity Bundle Total Care for the Total Sub-pop HIV/AIDS MLTC HARP Contracting Parties IPA/ACO, Large Health Systems, FQHCs, and Physician Groups IPA/ACO, FQHCs, Physician Groups and Hospitals IPA/ACO, FQHCs and Physician Groups

November 2016 Reminder: MCOs and Contractors can Choose Different Risk Levels of VBP Arrangements There are different levels of risk that the providers and MCOs may choose to take on in their contracts: Level 0 VBP* Level 1 VBP Level 2 VBP Level 3 VBP (feasible after experience with Level 2; requires mature contractors) FFS with bonus and/or withhold based on quality scores FFS with upside-only shared savings available when outcome scores are sufficient (For PCMH/IPC, FFS may be complemented with PMPM subsidy) FFS with risk sharing (upside available when outcome scores are sufficient) Prospective capitation PMPM or Bundle (with outcome-based component) FFS Payments Prospective total budget payments No Risk Sharing  Upside Risk Only  Upside & Downside Risk *Level 0 is not considered to be a sufficient move away from traditional fee-for-service incentives to be counted as value based payment in the terms of the NYS VBP Roadmap.

Contracting Entities / VBP Contractors
November 2016 Contracting Entities / VBP Contractors Independent Practice Associations (IPA) Accountable Care Organizations (ACO) Individual Providers Hospital Systems FQHCs and large medical groups Smaller providers including community based organizations (CBOs) Individual provider could either assume all responsibility and upside/downside risk or make arrangements with other providers; or MCOs may want to create a VBP arrangement through individual contracts with these providers

VBP Contractors: Independent Practice Association (IPA)
November 2016 18 VBP Contractors: Independent Practice Association (IPA) An Independent Practice Association is a corporation (nonprofit or for-profit) and/or LLC that contracts directly with providers of medical or medically related services, or another IPA in order to contract with one or more MCOs to make the services of such providers available to the enrollees of an MCO. Who negotiates the IPA contract? What is the governance of the IPA? Who should the individual provider look to if there are questions and/or concerns?

VBP Contractors: Independent Practice Association (IPA)
November 2016 19 VBP Contractors: Independent Practice Association (IPA) IPAs facilitate network development and access Single signature authority Typically for a category of services amongst competing providers (could be with providers across the care continuum) Allows providers to maintain independence regarding governance and clinical decision-making IPAs are not unions or guilds Antitrust concerns related to collective negotiation To avoid antitrust concerns, IPAs are usually entities that share risk or are clinically integrated IPAs can provide administrative services to providers who participate in the IPA and/or management services to MCOs

VBP Contractors: Accountable Care Organization (ACO)
November 2016 20 VBP Contractors: Accountable Care Organization (ACO) An Accountable Care Organization (ACO) is an organization of clinically integrated health care providers that work together to provide, manage, and coordinate health care (including primary care) for a defined population; with a mechanism for shared governance; the ability to negotiate, receive, and distribute payments; and accountability for the quality, cost, and delivery of health care to the ACO’s patients Medicare-only ACO (approved by CMS) for Medicare population Medicare ACO does not make you a Medicaid ACO and vice versa* IPAs may be certified by DOH as an ACO *There is an expedited approval process for Medicare ACOs to become Medicaid ACOs.

November 2016 21 Where Do You Fit in the Structure of a VBP Arrangement: Total Care for General Population (TCGP DOH MCO IPA/ACO Hospitals Physicians FQHCs BH Providers Pharmacies CBOs Ancillary Providers Flow of Funds

TCGP: Flow of Funds IPA/ACO to IPA/ACO Contract November 2016 22 DOH
MCO IPA/ACO Hospitals Physicians FQHCs Provider

November 2016 23 Where Do You Fit in the Structure of a VBP Arrangement: Total Care for a Subpopulation Flow of Funds DOH MCO FQHC IPA/ACO BH Provider Physicians Hospitals HCBS Provider CBOs Physician Group

November 2016 Where Do You Fit in the Structure of a VBP Arrangement: Integrated Primary Care (IPC) Flow of Funds DOH MCO Physician Groups DOH MCO FQHCs DOH MCO Hospital

November 2016 The Work of the Children’s VBP Subcommittee / Clinical Advisory Group (CAG)

Where Children Currently Factor in New York’s Systemic Approach to VBP
November 2016 26 Where Children Currently Factor in New York’s Systemic Approach to VBP TCGP Large-Scale Population Health Focused Providers About 2.1 million kids, ages 0-18, eligible to be included in these arrangements Measures from Advanced Primary Care (APC) preventive care set included, some with relevance for pediatric care, as well as chronic condition measures selected by CAGs & NYS IPC Professional Practices Focused on Primary Care Covers preventive care, routine sick care, and chronic condition management for 14 conditions (e.g. diabetes and asthma) for designated age ranges depending on episode parameters Measures include APC preventive care set as well as measures specific to chronic conditions, some with pediatric relevance Subpopulation Total Cost of Care for Designated Specialty Populations Covers all eligible services, care coordination is deemed a central value, and all general population as well as specialty measures (CAG & NYS selected) apply Example - HIV/AIDS includes about 1,600 children

Comprehensive Stakeholder Engagement
November 2016 27 Children’s Health VBP Subcommittee / Clinical Advisory Group (CAG) Composition: A Dual Approach Subcommittee CAG A geographically diverse group of leading experts and key stakeholders throughout NYS healthcare delivery system. Focus: to create recommendations to the State on VBP design Focus: to develop quality measures for VBP Arrangements Medical Societies State Agencies Centers Providers Universities Clinical Experts Health Plans Comprehensive Stakeholder Engagement

November 2016 28 Children’s Health VBP Subcommittee / Clinical Advisory Group: Objectives Understand the State’s vision for the Roadmap to Value Based Payment Review VBP arrangements for children’s services Develop a plain language value statement for the health and well-being of New York’s child and adolescent Medicaid beneficiaries Make recommendations to the State that reflect the value statement on: Overall design for children’s VBP, including populations / subpopulations Pertinent quality measures for children’s VBP arrangements Data and other support required for providers to be successful Implementation details related to VBP

Children’s Health Subcommittee / CAG Meeting Schedule
November 2016 29 Children’s Health Subcommittee / CAG Meeting Schedule Meeting #1 October 20 - Albany Introductions and Explanation of Roles Overview of VBP and Children's MRT Review of Children’s Medicaid Data and population distinctions Identification and Prioritization of Key Principles for Children’s VBP Meeting #2 November 18 - NYC Recap of Meeting #1 Children’s VBP Design Model Options for Children’s VBP Group to discuss Model Recommendations Group to discuss Key Implementation Considerations Preview of Quality Measures Meeting #3 December 12 - Albany Recap of Meetings #1 & 2 Quality Measures Overview Detailed Measure Review and Discussion Pediatric Health Pediatric BH Other (e.g. life outcomes; school readiness Quality Measure Selection and Recap Connection to Principles of Children’s VBP By the end of 2016, the recommendations put forth by the Subcommittee / CAG will be submitted and written into the recommendation report. The group will potentially reconvene in 2017 to ensure any outstanding items have been addressed.

Opening Platform to Inform Our Work
November 2016 Opening Platform to Inform Our Work Children Are Not Just Mini Adults! Early childhood development, social determinants of health, parental health, and clinical care all play a part in children’s wellbeing Ensuring that all children have access to high quality primary health care is important Early Interventions can have profound, long-term positive effects on children’s lifetime outcomes Value from improving child outcomes will accrue over a longer time frame and to society at large Cross-system collaboration is important as children follow their developmental trajectory

Starting Points for Selection of Quality Measures
November 2016 Starting Points for Selection of Quality Measures Alignment with DSRIP (avoidable hospital use) Reduce ‘drowning’ in measures phenomenon: outcome measures have priority Measuring the quality of the total cycle of care of the VBP arrangement Relevance for patients and providers Alignment with Medicare: linking to point of care registration (EHR) Alignment with State Heath Innovation Plan’s Advanced Primary Care measure set Transparency of process, of measures, of outcomes

Selecting and Refining Quality Measures is an Ongoing Process
November 2016 Selecting and Refining Quality Measures is an Ongoing Process CAG selects measures OQPS reviews measures VBP Workgroup sets measures Start of measurement End of year: evaluation results reported back to CAG Start During the process: Lists gets refined and reduced to those measures that really matter (specific to VBP arrangement) Key outcome measures Measures that are key to DSRIP success Nationally standardized key process measures Focus on outcomes will increase as outcome measures mature Pilots are essential to test feasibility and relevance of measures

November 2016 Health Homes Serving Children: Update on Readiness and Implementation Activities

Health Home for Children Begins
November 2016 34 Health Home for Children Begins On December 8th we will begin to enroll children in Health Home – A Major Step Forward in Medicaid Redesign Thank you for your patience and support during the design phase December 8th is just the beginning - we look forward to continuing to work with Health Homes, care managers, Plans and stakeholders to implement Health Homes for children and complete readiness activities

Status of Health Home Designations for Children
November 2016 35 Status of Health Home Designations for Children Designated Health Homes will begin to serve children December 8, 2016 16 Contingently Designated Health Homes have been working on readiness activities HIT Compliance – Care Management/EHR and Billing Readiness Network Adequacy ASAs with Managed Care Plans Policies and Procedures In Place Results of Health Home Serving Adults Re-designation Surveys Site Visits for Three Health Homes Serving Children Only Identified Contingencies Regular readiness calls regarding the Health Home Readiness Tool that highlights the areas of capacity, training, policies and procedures, etc. for Health Homes and network partners Review progress on concrete Health Home deliverables of MMIS ID #, BAAs, ASAs and Network Adequacy On November 4, 2016, the State issues letters to each of the 16 Health Homes regarding an assessment of their readiness to begin to enroll children on December 5, 2016 LANA

Status of Health Home Designations for Children
November 2016 36 Status of Health Home Designations for Children Of the 16 Health Homes Serving Children, 9 have been designated to begin enrollment effective December 8th. The county service area of one of those 9 was reduced pending completion of readiness activities The remaining 7 have not been designated to begin enrollment as of December 8 – readiness activities will continue. 3 are not Health Home Infrastructure Ready (2 did not meet HIT care planning requirements, 1 is not billing ready) 4 postponed – Received an adult re-designation performance level of 3, Performance Improvement Plan (PIP) must be submitted and demonstration PIP has been implemented State is committed to working with these Health Homes to move to readiness as quickly as possible Since the release of the November 4th designation letter, the State has met with each of the 7 Health Homes and is involved in ongoing discussions to move to readiness

Health Homes Designated to Serve Children for December 8, 2016
November 2016 37 Health Homes Designated to Serve Children for December 8, 2016 Health Home Counties Designated to Serve Children Designation Status to Serve Children Adirondack Health Institute, Inc. Clinton, Essex, Franklin, Hamilton, St. Lawrence, Warren, Washington Designated to Serve Children as of December 5, 2016 Catholic Charities of Broome County Encompass Catholic Charities Children’s Health Home Albany, Allegany, Broome, Cattaraugus, Chautauqua, Cayuga, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Erie, Essex, Franklin, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Niagara, Oneida, Onondaga, Ontario, Orleans, Otsego, Rensselaer, Saratoga, St. Lawrence, Steuben, Wayne, Wyoming, Yates (Readiness Activities Continuing, Not Authorized to Operate in the following counties: Fulton, Montgomery, Oswego, Schenectady, Schoharie, Schuyler, Seneca, Tioga, Tompkins, Warren, and Washington) Central New York Health Home Network (CNYHHN Inc.) Albany, Rensselaer, Schenectady, Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, St. Lawrence Readiness Activities Continuing, Not Authorized to Operate as of December 5, 2016

November 2016 38 Health Homes Designated to Serve Children for December 8, 2016 Health Home Counties Designated to Serve Children Designation Status to Serve Children Children’s Health Homes of Upstate New York, LLC (CHHUNY) Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Dutchess, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orange, Orleans, Oswego, Otsego, Putnam, Rensselaer, Rockland, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren, Washington, Wayne, Wyoming, Yates Designated to Serve Children as of December 5, 2016 Collaborative for Children and Families Bronx, Brooklyn, Manhattan, Nassau, Queens, Staten Island, Suffolk, Westchester Coordinated Behavioral Care, Inc. dba Pathways to Wellness Health Home Bronx, Brooklyn, Manhattan, Queens, Staten Island Greater Rochester Health Home Network LLC Cayuga, Chemung, Livingston, Monroe, Ontario, Seneca, Steuben, Wayne, Yates, Allegany, Genesee, Orleans, Wyoming Readiness Activities Continuing, Not Authorized to Operate as of December 5, 2016 Hudson River HealthCare, Inc. dba Community Health Care Collaborative Columbia, Dutchess, Greene, Orange, Putnam, Rockland, Sullivan, Westchester, Nassau, Suffolk

November 2016 39 Health Homes Designated to Serve Children for December 8, 2016 Health Home Counties Designated to Serve Children Designation Status to Serve Children Institute for Family Health Ulster Readiness Activities Continuing, Not Authorized to Operate as of December 5, 2016 Kaleida Health-Women and Children’s Hospital of Buffalo Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming Montefiore Medical Center dba Bronx Accountable Healthcare Network Health Home Bronx Designated to Serve Children as of December 5, 2016 Niagara Falls Memorial Medical Center Niagara North Shore LIJ Health Home Queens, Nassau, Suffolk Mount Sinai Health Home Serving Children Bronx, Brooklyn, Manhattan, Queens, Staten Island St. Mary’s Healthcare Fulton, Montgomery VNS – Community Care Management Partners, LLC (CCMP)

November 2016 40 Prioritizing the Enrollment of Eligible Children in Health Homes: December 2016 Begin Date for Enrollment To manage initial capacity (and provide time to build up capacity) Health Homes, LDSS, LGU, Care Managers and Plans, should prioritize the enrollment of children that meet Health Home chronic condition eligibility and appropriateness criteria and have the highest needs, including the following: Children enrolled in OMH TCM care management programs that will convert to Health Home Children on OMH Waiver waiting list (already Medicaid eligible), within 30 days of discharge from inpatient/residential/day treatment settings to participate in discharge planning Children on TCM waitlist; [SPOA who refers to HH] Children who are on the Bridges to Health (B2H) Wait list, Children in licensed congregate care, Children that are within 3 months of foster care discharge, Children enrolled in LDSS prevention services where foster care placement is imminent, Children prescribed 3 or more psychotropic medications Children who are within 30 days of discharge from inpatient, residential or detox setting Medically Fragile Children with multiple chronic conditions that have had recent (past 30 days) inpatient stay Children who have an ER referral but are not admitted for inpatient services; or are discharged with a recommendation for community follow up; Children with multiple system involvement (child welfare, criminal justice) Children in Early Intervention (EI) target date to be enrolled March 2017 (when procedures for integrating EI and HH requirements have been established, with stakeholder feedback, and trainings provided).

November 2016 41 Leveraging the Expertise of OMH TCM Providers that will Transition to Health Home To more fully leverage the expertise of OMH TCM providers and the Single Points of Access (SPOAs) to preserve the delivery of high quality care management to children with Serious Emotional Disturbance (SED) under the Health Home program, the OMH and DOH are working together to integrate processes which will incorporate SPOA referrals to OMH TCM providers and other requirements for OMH TCM providers that transition to Health Home

November 2016 42 New Process for Serving SED Children in Health Homes: Role of the SPOA and Health Home Care Manager Assignments Current Health Home Requirements: Health Homes and Care Management Agencies are required to ensure that CMAs providing Health Home care management are qualified to meet the needs of the child and family (e.g., be able to meet the care management needs of a child with SED, that has HIV, or has multiple chronic conditions) New Process: Beginning in December, Children that are identified to be eligible for Health Home because they have or potentially have an SED through the SPOA process will be referred by the SPOA to a “Designated Health Home Care Management Agency (CMA) for SED” Designated HH CMAs for SED will be existing OMH TCM Programs that are transitioning to Health Home SPOA will assign SED children to Designated HH CMA for SED SPOA assignments must reflect alignment between Health Home, Designated HH CMAs for SED, and Managed Care Plans for children enrolled in Plans Health Home has BAA with Designated HH CMA for SED, Plan the child is enrolled in has ASA in place with that same Health Home

November 2016 43 New Process for Serving SED Children in Health Homes: Role of the SPOA and Health Home Care Manager Assignments SPOA assignments are limited, on a Designated HH CMA for SED basis, to the current capacity for Medicaid children served by the existing TCM, (i.e., 3,000 children statewide) - “SPOA Assignment” Designated HH CMA for SED will “assign” children with a CANS-NY acuity of High or Medium to a SPOA Assignment Children with CANS-NY acuity of low or that step down from High or Medium to Low will continue to be served by HH CMA for SED but does not count towards SPOA Assignment SPOA will track and report the number of assignments made to each Designated HH CMA for SED to OMH and DOH and each Lead Health Home – this will be a manual process that will occur outside of the MAPP HHTS SPOAs will use only use the MAPP HHTS to make a referral for assignment through the MAPP HHTS Children’s Referral Portal if the Designated HH CMA for SED does not have capacity to serve that child (i.e., their SPOA Assignments are filled) or for other non-SED referrals

November 2016 44 New Process for Serving SED Children in Health Homes: Role of the SPOA and Health Home Care Manager Assignments SPOA recommendation is subject to family / child choice, family may choose and be informed of other Health Homes CMAs non-designated for SED Health Homes may also make assignments to Designated HH CMAs for SED HH CMAs non-designated for SED that may be working with children and families with SED Children may continue to directly enroll such children through the MAPP HHTS Children’s Referral Portal

November 2016 45 New Requirements for Serving SED Children in Health Homes: Case Load Sizes for Designated HH CMAs for SED Current Health Home Requirements: Health Homes are required to provide a level of service, (e.g., number of contacts and methods of contact), that support the needs of the child and the family and meet the Health Home core requirements Health Homes and care managers serving children with high acuity per the CANS-NY are required to keep their case loads mix predominantly to children of the High acuity level Children with High and Medium acuity per the CANS-NY are required to receive two Health Home services per month, one of which must be a face-to-face encounter with the child Case load sizes have been built into the development and calculation of the Health Home rates for children – presumption is CMAs will manage case loads around these assumptions The rates assume underlying case load ratios of 1:12 for “High”, 1:20 for “Medium” and 1:40 for “Low” New Requirements: Designated HH CMAs for SED will be required to maintain the case load ratios built into the rates for children that are referred by the SPOA 1:12 for High 1:20 for Medium 1:40 for Low

November 2016 46 New Requirements for Serving SED Children in Health Homes: Care Manager Qualifications Current Health Home Requirements: Care Managers that serve children with an acuity level of “high” as determined by the CANS-NY are required to have: A Bachelors of Arts or Science with two years of relevant experience, or A License as a Registered Nurse with two years of relevant experience, or A Masters with one year of relevant experience. Providers may seek a waiver qualifications waiver from the State New Requirements: Designated HH CMAs for SED serving children with medium acuity that do not have CMA qualifications of at least an associates degree with one year of relevant experience must notify the State and seek a waiver from such qualifications

Next Steps Week of December 5th – Posted on the Health Home Webpage
November 2016 47 Next Steps Week of December 5th – Posted on the Health Home Webpage DOH/OMH will provide SPOAs and Designated HH CMA for Children w/SED of the number of SPOA assignments by County and Agency DOH/OMH will provide, to SPOAs, the MMIS of Health Homes and Designated HH CMA for SED for their County DOH/OMH will provide, to SPOAs, HH, Plan and CMA Alignment for their County DOH/OMH will provide the initial roster data collection tool Week of December 12th – Webinar and Web Posting DOH/OMH will provide the SPOAs with the SPOA tracking form SPOA training Webinar on Data Collection and use of tracking form

Subscribe to the HH Listserv
November 2016 48 Subscribe to the HH Listserv Stay up-to-date by signing up to receive Health Home updates Subscribe .htm Health Home Bureau Mail Log (BML) es/ HealthHome.action

Please send any questions, comments or feedback on Health Homes Serving Children to: or contact the Health Home Program at the Department of Health at Stay current by visiting our website: gram/medicaid_health_homes/health_homes_and _children.htm

Children’s Medicaid Redesign and Value Based Payments (VBP)

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Children’s Medicaid Redesign and Value Based Payments (VBP)

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