Redesign Medicaid in New York State Implementing Medicaid Behavioral Health Reform in New York Status Update 10th Annual Executive Seminar on Systems Transformation April 24, 2014 BHO Phase 2 Status Revised RFQ based on RFI comments RFQ distributed (with draft NYC HARP rates) on March 21, 2014 Inquiries due electronically by April 30, 2014 OMH: http://www.omh.ny.gov/omhweb/bho/phase2.html DOH: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health_transition.htm Non-Mandatory RFQ Applicant’s Conference on May 2, 2014 in NYC Email to register: [email protected] (by April 23rd) NYC Applications due June 6, 2014 Rest of State - approximately six months later 2 Behavioral Health Manged Care Transition Timeline NYC implementation 1/1/15 POST RFQ EARLY TO MID MARCH NYC Final rates available April 2014 1 Feb 1 Mar BEGIN MEMBER NOTIFICATION OF HARP PASSIVE State review /designationENROLLMENT* PLAN RESPONSES DUE 1 Apr Public Notice of OASAS SPA (3/5/14) InterRAI functional assessment tool pilot 5/1/14-7/1/14 1 May 1 Jun 1 Jul and revision as needed-NYC RFQ responses 6/1/14-10/1/14 1 Aug 1 Sep NYC IMPLEMENTATION NYC Plan Readiness Review 8/29/14-11/1/14 1 Oct 1 Nov Statew ide MC-Provider start-up assistance ($20M)* 1 Dec 1 Jan 1 Feb 1 Mar Building statew ide capacity for 1915(i)-like services begins 10/1/14** ($30M) *Statewide MC-Provider start-up: - Funds to ensure adequate networks are in place prior to implementation of BH MC - Plan/Provider/HH technical assistance for electronic medical records and billing - Funds to build BH provider (Children and Adults) infrastructure **Building statewide 1915(i)-like service capacity involves: - 1915(i)-like network development - Funding 1915(i)-like functional assessments - Funding for 1915(i)-like services starting January 1, 2015 2/11/2014 3 RFQ Standards 4 RFQ Performance Standards Organizational Capacity Cross System Collaboration Experience Requirements Quality Management Contract Personnel Reporting and Performance Management Member Services Claims Processing Information Systems and Website Capabilities Network Service Network Monitoring Network Training Financial Management Utilization Management Performance Incentives Clinical Management Implementation planning 5 Contract Personnel HARPs must have full time dedicated BH Medical and Clinical Director These positions may be shared if the HARP has fewer than 4,000 State identified HARP eligibles Subject to certain restrictions, Plans may share positions and functions between Mainstream MCOs and HARPs Plans must demonstrate to NYS that they or their managerial staff meet the experience requirements established in the RFQ Plans must demonstrate that they have an adequate number of managerial and operational staff to meet the needs of their members. 6 Utilization Management Plans must use medical necessity criteria to determine appropriateness of ongoing and new services Plans prior authorization and concurrent review protocols must comport with NYS Medicaid medical necessity standards These protocols must be reviewed and approved by OASAS and OMH in consultation with DOH Plans will rely on the LOCADTR tool for review of level of care for SUD programs as appropriate HARP UM requirements must ensure person centered plan of care meets individual needs 7 Clinical Management The RFQ establishes clinical requirements related to: The management of care for people with complex, high-cost, co occurring BH and medical conditions Promotion of evidence-based practices Pharmacy management program for BH drugs Integration of behavioral health management in primary care settings Additional HARP requirements include oversight and monitoring of: Health Home services and 1915(i) assessments Access to 1915(i)-like services Compliance with conflict free case management rules (federal requirement) Compliance with HCBS assurances and sub-assurances (federal requirement) 8 Network Service Requirements Plan’s network service area consists of the counties described in the Plan’s current Medicaid contract There must be a sufficient number of providers in the network to assure accessibility to benefit package Transitional requirements include: Contracts with OMH or OASAS licensed or certified providers serving 5 or more members for a minimum of 24 months Pay FFS government rates to OMH or OASAS licensed or certified providers for ambulatory services for 24 months. Option for alternative payment models if all parties agree and NYS approves State will review proposed Plan/provider alternative payment arrangements requirements on a case by case basis 9 Network Service Requirements Plans must contract with: Opioid Treatment programs to ensure regional access and patient choice where possible Health Homes Plans must allow members to have a choice of at least 2 providers of each BH specialty service Must provide sufficient capacity for their populations Contract with crisis service providers for 24/7 coverage Plans contracting with clinics with state integrated licenses must contract for full range of services available HARP must have an adequate network of Home and Community Based Services Network Training Plans will develop and implement a comprehensive BH provider training and support program Topics include: Billing, coding and documentation Data interface UM requirements Evidence-based practices HARPs train providers on HCBS requirements Training coordinated through Regional Planning Consortiums (RPCs) when possible RPCs are comprised of each LGU in a region, representatives of mental health and substance abuse service providers, child welfare system, peers, families, health home leads, and Medicaid MCOs RPCs work closely with State agencies to guide behavioral health policy in the region, problem solve regional service delivery challenges, and recommend provider training topics RPCs to be created 11 Year One Performance Measures Year One Performance Measures Existing QARR and Health Home measures for physical and behavioral health for HARP and MCO product lines BHO Phase 1 measures will continue to be run administratively New measures being proposed for HARPs based on data collected from 1915(i) eligibility assessments Member Satisfaction – all are existing QARR measures Based on CAHPS survey A recovery focused survey for HARP members is also being developed. Measures derived from this survey may be created in the future 12 Financial Management HARP rate does not include 1915(i) home and community based services In the first year, HCBS paid on a non-risk basis Plans will act as an Administrative Services Organization (ASO) NYS will identify and designate 1915(i) providers NYS will establish initial 1915(i) payment rates 13 Next Steps 14 Next Steps Ongoing Plan Engagement Plan/Health Home collaboration: Identify care management roles and responsibilities beyond the existing Health Home/Plan agreement Determine the care management model for HARP members and HARP eligibles that are not enrolled in Health Homes Building Health Home capacity for HARP enrollees Work with Plans and Health Home to collect and analyze Health Home performance 15 Next Steps 1915i program development Develop guidance for 1915i services Designating 1915i qualified providers Work with CMS to streamline assurances/sub-assurances Finalize Year 2 performance measures NYS will develop a Regulatory Reform Workgroup Provide ongoing technical assistance for Plans and providers Implement Start-Up Activities (with funding in 2014-15 Executive Budget) Facilitate creation of Regional Planning Consortiums (RPCs) 16
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