Monday, June 30, Support for this webinar provided by the Substance Abuse and Mental Health Services Administration

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Buddy Adams
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1 Monday, June 30, 2014 Support for this webinar provided by the Substance Abuse and Mental Health Services Administration 1

2 All lines will be muted during the presentation. To comment or ask a question during that time, please use the Chat Box feature. Are you hearing an echo? Try turning your computer speakers off. The webinar recording and presentation slides will be made available on NASMHPD s website. 2

3 How do you take apart some of the Medicaid requirements and authorities and put them together in a Recovery-Oriented System of Care? Delivery System Options Care Management Delivery Options Braiding of Funding Home and Community-Based Services (HCBS) What are home and community based services (HCBS)? Why behavioral health (BH) HCBS? What States have implemented BH HCBS? What are some new innovative Recovery Oriented programs? Opportunities Risks Creativity Risk mitigation Questions 3

4 Delivery System Financing Each State needs to examine the incentives that are needed in the delivery system. Capitation Some States choose to transfer the operations and risk of the program to an insurance company (e.g., North Carolina) Non-risk Some States choose to transfer only the operations of the program and keep the risk with the State. This is especially the case when the State is uncertain how much a new program will cost, is concerned about financial incentives for disincentivizing needed care, or about the FFS program having widespread access issues (e.g., historic Kansas, New York pending adult mental health program, and Louisiana children s program) Fee-for-service Some States choose to keep the operations and financial risk with the State and only contract out limited administrative functions such as utilization review (e.g., Georgia) 4

5 Targeted Care Management (TCM) Managed Care Treatment Planning (MC TP) HCBS Case Management service under a waiver/spa Administrative Case Management (ACM) Health Homes (HH) 5

6 Each option has distinct pros and cons for financing and delivering Care Management for SPMI. TCM has heightened CMS scrutiny for approval and reimbursement. MC TP is only in risk and non-risk contracts. HCBS Case Management is a service subject to the new HCBS regulations. ACM has lower match rate and cannot arrange for non- Medicaid services. HH have their own statutory requirements. 6

Inpatient and outpatient hospital Physician Pharmacy SUD services Rehabilitation services (Optional) Other licensed practitioners (Optional) EPSDT services for children including medically necessary

7 Inpatient and outpatient hospital Physician Pharmacy SUD services Rehabilitation services (Optional) Other licensed practitioners (Optional) EPSDT services for children including medically necessary optional services not in the State Plan Supported Employment Respite Habilitation Residential Supports One-time transitional services SUD prevention services Room and Board Services for non-medicaid eligibles 1905(a) State Plan Services Medicaid HCBS and waiver services Services funded with non-medicaid 7

8 HCBS services are an array of home and communitybased services. HCBS promote community living for Medicaid beneficiaries and, thereby, avoid institutionalization. HCBS services complement and/or supplement the services that are available through the Medicaid State plan under 1905(a) of the Social Security Act. HCBS services do not duplicate other Federal, state and local public programs or supports that families and communities provide to individuals. 8

HCBS services that cannot be authorized in the regular State Plan (Adults or Children) Respite Supported Employment Habilitation Supported Housing Homemaker/chore Case Management Extended State Plan

9 HCBS services that cannot be authorized in the regular State Plan (Adults or Children) Respite Supported Employment Habilitation Supported Housing Homemaker/chore Case Management Extended State Plan Services (Adults) State Plan services beyond the limits in the State Plan such as additional physician visits, additional prescriptions, additional home health aide visits, personal care, or additional clinic visits for adults Optional Services not in the State s Medicaid State Plan (Adults) Assertive Community Treatment Peer Support Day Treatment/partial hospitalization Psychosocial Rehabilitation Clinic Other services approved by the Secretary HCBS services that cannot be authorized in State Plan Other HCBS services 9

Primary authorities are: 1915(c) HCBS waivers (institutional level of care) 1915(i) HCBS State Plan Amendments (needs-based criteria) 1115 demonstrations can be used to authorize HCBS services for

10 Primary authorities are: 1915(c) HCBS waivers (institutional level of care) 1915(i) HCBS State Plan Amendments (needs-based criteria) 1115 demonstrations can be used to authorize HCBS services for individuals meeting institutional level of care or meeting needs-based criteria 1915(k) Community First Choice (CFC) 1915(a) voluntary managed care 1915(b)(3) services paid for through waiver savings Note: several states are embedding HCBS in their larger 1115 demonstration and 1915(b) waivers, which allow the States to adopt additional freedom of choice and selective contracting authorities or other particular waivers when combined under MLTSS programs in comprehensive risk and non-risk contracts. 10

11 Eligibility evaluation required Requires institutional level of care equal to state s current admission criteria May use institutional financial eligibility Allowed to limit slots and geography May offer self-direction Must comply with CMS assurances HCBS services defined by State May have cost caps Eligibility evaluation required Must meet level of need less than existing state institutional admission criteria Statutory requirement for independent assessment Target population may have risk factors identified May use institutional financial eligibility and may have presumptive eligibility for 60 days Financial eligibility is less than 150% FPL unless the individual is eligible for an existing 1915(c) waiver May have an enrollment target and if exceed may modify future eligibility criteria Must be statewide (phase in allowed) May offer self-direction Must comply with CMS assurances HCBS services defined by State No cost of care cap permitted 1915(i) State Plan 1915(c) Waiver 11

12 Evaluation to determine program eligibility Assessment of need for services Plan of care Quality Assurance requirements Service Options Self-Direction Option Option to not apply income and resource rules for the medically needy 12

1915(c) requires institutional level of care requirements 1915(i) requires no renewal to continue operations unless populations are targeted

13 1915(c) requires institutional level of care requirements 1915(i) requires no renewal to continue operations unless populations are targeted 1915(c) may Limit Number of Participants 1915(c) has option to Limit Statewideness 1915(c) requires cost-neutrality and financial estimates 13

14 BH HCBS allow States to utilize Medicaid funding to provide services and supports for Recovery- Oriented Systems of Care and address: Legal challenges to the provision of services in institutional settings without providing similar services in the community (Olmstead) Financial challenges with State and block grant funding requiring diversification of funding streams to create more sustainable programs Acuity challenges as populations age and programs address co-occurring diagnoses 14

15 Include historic home and community based programs authorized under traditional HCBS authorities and delivery systems that have changed over time Connecticut 1915(c) adult waiver New York SED and B2H children s waivers Kansas SED children s waiver States with 1915(i) State plan HCBS (as of July 2011) Iowa Nevada Colorado Washington Wisconsin Idaho 15

16 The new wave of programs include: North Carolina MH/DD/SAS capitated program Louisiana Behavioral Health Program including an adult 1915(i) program and a children s Coordinated System of Care New Jersey 1115 demonstration authorized a Medication Assisted Treatment Initiative (MATI) for adults and a Serious Emotional Disturbance (SED) expansion for the Children s System of Care Pending/announced but not approved authorities include: Delaware PROMISE program New York Adult Behavioral Health Texas HCBS for Adult Mental Health *Note: these slides were developed based on the latest publically available information and may not reflect the current status of amendments and CMS negotiations. 16

17 Authority: 1915(b)(c) Medicaid concurrent waivers and an additional 1915(i) SPA Populations: 1915(b)(c) concurrent waivers provide HCBS services to individuals with SPMI, SUD and ID/DD 1915(i) provides HCBS services to individuals 21 years of age or older with a primary care with particular diagnoses who are eligible for Special Assistance and have been diagnosed with a major psychiatric diagnosis Delivery system: Capitated managed care organizations Care Management: Managed Care Treatment Planning Olmstead settlement state 17

18 Inpatient hospital psych Emergency room services with primary MH/SA/DD diagnosis Outpatient Clinic Psychiatrist Services Behavioral Health long-term residential children Mobile crisis management Professional Treatment in facility based crisis Diagnostic assessment Community Support Prescribed Drugs Behavioral Health State Plan Services Targeted Case Management Assertive Community Treatment Team Multi-Systemic Therapy Intensive in-home services Child/Adolescent day treatment Partial hospitalization Psychosocial rehabilitation Detoxification SA - Residential rehabilitation SA Outpatient Rehab Opiod Treatment ICF/IDD 18

19 Respite Supported Employment Integrated Medical Services Personal Care/Individual Support One-Time Transitional Costs Peer Supports IDD services for children and adults exiting ICF-MRs Physician Consultation Community Guide In-home Skill Building (pilot) Transitional Living Skills (pilot) 1915(i) Alzheimer s and Dementia services (ADL personal assistance) 1915(b) (3) services MH/SUD/IDD populations 1915(i) SPA 19

20 Personal Care Residential Supports Day Supports Supported Employment Respite Assistive Technology Equipment and Supplies Community-Guide Community-Networking Community Transition Services 1915(c) services ID/DD populations Crisis services In-Home Skill-building In-Home Intensive supports Home modifications Individual Goods and Services Natural Supports Education Specialized Consultation Services Vehicle Modifications 20

21 Authority: 1915(b)(c) (i) Medicaid concurrent authorities Populations: 1915(b)(c) (i) concurrent authorities provide HCBS services to individuals with SMI, SED and SUD and allow the state to target specialized services to at-risk children Delivery system: Capitation for Adults; non-risk for Children with care management through wraparound agencies utilizing a High Fidelity Wraparound Model Care Management: Managed Care Treatment Planning Adult program was developed in conjunction with Supported Housing Program 21

22 Hospital inpatient and outpatient Pharmacy Physician Substance Use Disorder Treatment Licensed Mental Health Practitioners Crisis Intervention Therapeutic Group Homes Psychiatric Residential Treatment Facilities Community Psychiatric Support and Treatment Psychosocial Rehabilitation School-based services All populations State Plan Medicaid Services Children s EPSDT State Plan Services 22

23 Licensed Mental Health Practitioners Crisis Intervention Therapeutic Group Homes Community Psychiatric Support and Treatment Psychosocial Rehabilitation Wraparound Facilitation Independent Living/Skills building Short Term Respite Youth Support and Training Family Support and Training Crisis Stabilization Adult 1915(i) Services Children s Coordinated System of Care [1915(c) and 1915(b)(3)] 23

24 Authority: 1115 Demonstration Populations: Adults 18 years and Older with Substance Use Disorders at risk of institutionalization Children under age 21 with Serious Emotional Disturbances who are at risk of hospitalization or who meet institutional level of care Children ages 5-21 with developmental disabilities and cooccurring mental health diagnoses meeting institutional level of care Delivery system: FFS with an Administrative Contractor performing management functions Care Management: Differs depending upon the program Olmstead settlement state 24

25 Methadone Suboxone Medication monitoring Assessment Counseling Therapy (individual, group & family) Case management; Urine Screening Intensive Outpatient Program TB test Crisis Intervention in a facility Short and Long Term SUD Residential Halfway House Detoxification Medically Enhanced Detoxification Children in SOC otherwise eligible for Medicaid receive all Medicaid services Children in SOC not otherwise eligible for Medicaid receive the Medicaid State Plan Behavioral Health Services All SOC children receive these three HCBS services: Transitioning Youth Life Skill Building Youth Support and Training Non-medical transportation Adult MATI Program Children s SOC Program 25

26 Case/Care Management Individual Supports Natural Supports Training Intensive In-Community Services Habilitation Respite Non-Medical Transportation Interpreter Services Note: the purpose of this program is to stabilize the child in the least restrictive environment. Many children are served in group homes for one resident until the child is able to return home. The program works to provide positive behavior supports to develop appropriate and safe ways to redirect the child. Children with ID-DD/MI Children with IDD/MI 26

Authority: 1115 Demonstration (Amendment Pending CMS approval) implementation planned Summer Fall 2014 Population: Adults over age 18 meeting SPMI and SUD targeting and functional needs criteria or

27 Authority: 1115 Demonstration (Amendment Pending CMS approval) implementation planned Summer Fall 2014 Population: Adults over age 18 meeting SPMI and SUD targeting and functional needs criteria or who previously met the targeting and functional criteria and needs subsequent medical necessary services for stabilization and maintenance. The individual continues to need at least one HCBS service for stabilization and maintenance. Delivery system: Fee-for-service Olmstead settlement state Linked to Governor s initiative on Employment Care Management: HCBS Care Management 27

28 Care Management Benefits Counseling Community Psychiatric Support and Treatment Community-based residential supports, excluding assisted living Financial Coaching Independent Activities of Daily Living/Chore Individual Employment Supports Non-medical Transportation Nursing Peer Support Personal Care Psychosocial Rehabilitation Respite Short-term small group supported Employment Community Transition Services 28

29 Authority: 1115 Demonstration (Amendment Pending CMS approval) implementation planned January 1, 2015 Delivery system: Fully capitated Health and Recovery Plans (HARPS) which are specialty lines of business within qualified mainstream MCOs with care management through health homes. Note: HCBS services for SPMI/SUD will be financed through nonrisk payment to HARPs initially Care Management: Health Homes Olmstead litigation state 29

30 Population: Medicaid MCO beneficiaries who meet SMI or SUD targeting criteria and risk factors are eligible for HARP enrollment All individuals in the HARP will be evaluated for eligibility for HCBS services via a conflict-free evaluation/assessment. Individuals meeting one of the needs-based criteria will be eligible for HCBS services. 30

31 Needs-based criteria for adult HCBS services include: An individual with at least "moderate" levels of need An individual with need for HCBS services and a risk factor of a newly-emerged psychotic disorder. A HARP enrolled individual who either previously met the needs-based criteria or has one of the needs based historical risk factors; AND who is assessed and found that, but for the provision of HCBS for stabilization and maintenance purposes, would decline to prior levels of need (i.e., subsequent medically necessary services and coordination of care for stabilization and maintenance is needed to prevent decline to previous needs-based functioning). 31

32 Rehabilitation Psychosocial rehabilitation Community Psychiatric Support and Treatment (CPST) Crisis Intervention Peer Supports Habilitation Habilitation Residential Supports/Supported Housing (excluding room and board and food) Respite Short-term Crisis Respite Intensive Crisis Respite Non-medical transportation Family Support and Training Employment Supports Pre-vocational Transitional Employment Intensive Supported Employment On-going Supported Employment Education Support Services Supports for self-directed care (phased in as a pilot): Financial Management services and Participant Supports 32

33 Authority: 1915(i) SPA (Pending CMS approval) Population: Adults with extended, repeated inpatient psychiatric commitment or a history of extended commitment without repeat commitment and a risk factor of extended tenure in inpatient psychiatric hospital meeting a level of need. Note: CMS was concerned about restricting eligibility to those currently hospitalized and restricting eligibility from those who meet inpatient psychiatric admission criteria and who must be given a choice of HCBS or institution. State MH authorities need to understand the historical HCBS perspective and requirements of CMS in order to "translate to CMS for approval. Delivery system: Fee-for-Service Care Management: HCBS Case Management 33

34 Transition Assistance Services (up to $2,500) Adaptive aids and medical supplies Employment Services Transportation Community Psychiatric Supports and Treatment Peer Support Community-based Residential assistance services Respite Home Delivered Meals Minor Home Modifications Nursing SUD services Rehabilitation Services HCBS- AMH Recovery Management 34

35 Addressing co-occurring populations (North Carolina) Specialized delivery systems (HARPs in New York) Braiding Funding Streams (Louisiana) Utilizing risk factors to target populations (New York and Texas) Seeking multiple CMS authorities to obtain the combination needed for the programs (Louisiana and North Carolina) 35

36 1915(i) Specifically: does not include an institutional level of care nor cost neutrality requirement Has specific HCBS services for persons with chronic mental illness (but not limited to): Day Treatment or Partial Hospitalization Psychosocial Rehabilitation Clinic Services Recovery Oriented care is consistent with HCBS person-centered planning HCBS care management functions of assessment, plan of care development, referral, and monitoring of each individual s plan of care is consistent with good behavioral health care management 36

37 CMS policy changes constantly States have historical delivery systems and stakeholders with economic issues that need to be addressed (e.g., PRTFs, Assisted Living, Adult Care Homes, Nursing Facilities, Day Treatment providers) Accessibility issues in services and housing Complexity (Louisiana) 37

38 Competing federal statutory requirements (e.g., New York behavioral health home and BIP conflict free case management requirements) Budget impact if population is not appropriately targeted and limitations of 1915(i) versus 1915(c) Burden of HCBS assurance compliance Application of the recently released final rule across all HCBS authorities (e.g., HCBS setting, conflict free case management) 38

39 Some states are removing the mental health Clinic Option from the State Plan, utilizing HCBS authorities to target services in the community to the SMI that were once provided only within the four walls of a clinic, and ensuring that evidencebased practices are fully financed when implemented with fidelity Placing generic services in the State Plan with prior authorization for evidence-based practices 39

40 Once a state has identified a target population, the next step is to design a benefit package to address the needs of that population. Today, more opportunities exist than ever before for financing evidence-based practices and ensuring that reimbursement adequately compensates providers for complying with fidelity CMS has approved multiple new programs that utilize HCBS and Medicaid funding to further these aims and is in the process of approving several more 40

41 Embracing the new CMS HCBS assurances during program design Ensuring that program operations gather sufficient information to monitor the health and welfare of individuals Ensuring that conflict mitigation strategies are developed to protect person-centered planning and offset provider influence in plan of care development 41

42 42

43 Brenda Jackson Consulting, LLC Brenda Jackson Consultant 511 Canyon Dr Lawrence, KS Phone:

MEDICAID MANAGED LONG-TERM SERVICES AND SUPPORTS OPPORTUNITIES FOR INNOVATIVE PROGRAM DESIGN

Louisiana Behavioral Health Partnership MEDICAID MANAGED LONG-TERM SERVICES AND SUPPORTS OPPORTUNITIES FOR INNOVATIVE PROGRAM DESIGN Rosanne Mahaney - Delaware Lou Ann Owen - Louisiana Brenda Jackson,