October 9, The Managed Care Technical Assistance Center of New York

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1 October 9, 2015 The Managed Care Technical Assistance Center of New York

2 MCTAC Overview Adult BH HCBS Overview Workflow Who s On First and Residential Exclusionary Settings Eligibility CAPs Overview Program/Services Overview Checklist Plan of Care (POC) Template Communication Upcoming Events

3 MCTAC is a training, consultation, and educational resource center that offers resources to all mental health and substance use disorder providers in New York State. MCTAC s Goal Provide training and intensive support on quality improvement strategies, including business, organizational and clinical practices to achieve the overall goal of preparing and assisting providers with the transition to Medicaid Managed Care.

4 Who is MCTAC?

5 MCTAC Partners

6 Adult BH HCBS Overview

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8 Adult BH HCBS Approved Settings OMH Supported Housing Independent Community Housing Still Under Review OMH Apartment Treatment Programs OMH CR-SRO OMH SP-SRO OMH 100% special needs SP-SRO OMH SP-SRO Mixed Use OASAS Supportive Living OASAS Residential Reintegration/Scatter Site Setting Adult BH HCBS Disapproved Settings OMH Community Residence OMH Adult Home OMH Housing located adjacent to and on State Hospital Grounds (not for profit and state run) OASAS Intensive Residential OASAS Community Residence OASAS Inpatient Rehab OASAS Residential Rehabilitation OASAS Residential Reintegration/Congregate Setting

9 Summary of CMS Final Rule Regarding Settings The CMS final rule requires that all Home and Community Based settings meet certain qualifications. These include that the setting: Is integrated in and supports full access to the greater community; Is selected by the individual from among setting options; Ensures individual rights of privacy, dignity, and respect, and freedom from coercion and restraint; Optimizes autonomy and independence in making life choices; and Facilitates choice regarding services and who provides them

10 Under the final CMS rule, in a provider-owned or controlled residential setting, the following conditions must be met: 1) The unit can be owned, rented or occupied under an agreement by the individual receiving services, and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under landlord tenant law. 2) Each individual has privacy in their sleeping or living unit: Units have entrance doors lockable by the individual, with only appropriate staff having keys to doors as needed. 3) Individuals sharing units have a choice of roommates in that setting. 4)Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement. 5) Individuals have the freedom and support to control their own schedules and activities, and have access to food at any time. 6) Individuals are able to have visitors of their choosing at any time. 7) The setting is physically accessible to the individual.

11 State Identified HARP Eligible Available on EPACES Must meet NYS CMHA Criteria Tier 1 -- Services include employment, education and peer supports services Tier 2 -- Includes the full array of Adult BH HCBS

12 Code H1 - HARP enrolled without HCBS eligibility- This code identifies the person as enrolled in a HARP (Health and Recovery Plan). It also indicates that the person is NOT eligible for the special HARP wrap-around Home and Community Based Services (HCBS). Code H2 - HARP enrolled with Tier 1 HCBS eligibility- This code identifies the person as enrolled in a HARP. It also indicates that the person has been assessed and determined to be eligible for Tier 1 HCBS services (peer supports, employment supports, education supports). Code H3 - HARP enrolled with Tier 2 HCBS eligibility- This code identifies the person as enrolled in a HARP. It also indicates that the person has been assessed and determined to be eligible for Tier 2 HCBS services (which includes all Tier 1 services listed under H2, plus psychosocial rehab, community psychiatric supports and treatment, etc.).

13 Code H4 - HIV SNP HARP eligible without HCBS eligibility- This code identifies the person as HARP eligible, but with enrollment in an HIV SNP. They have NOT been determined to be eligible for the special HCBS benefit package associated with some HARP eligibles. Code H5 - HIV SNP HARP eligible with Tier 1 HCBS eligibility- This code identifies the person as HARP eligible, but with enrollment in an HIV SNP. It also indicates they have been assessed and determined to be eligible for the Tier 1 HCBS services, which will be administered by their HIV SNP. Code H6 - HIV SNP HARP eligible with Tier 2 HCBS eligibility- This code identifies the person as HARP eligible, but with enrollment in an HIV SNP. It also indicates they have been assessed and determined to be eligible for the Tier 2 HCBS services, which will be administered by their HIV SNP. Code H7 - Opted Out of HARP- This indicates a person was HARP- eligible but who, when given the option to enroll, declined enrollment.

14 Code H8 - State- identified for HARP Assessment- This code indicates the person has been identified by OMH, OASAS, DOH, or another designated entity as potentially HARP eligible. An assessment will need to be done on the person and if the results of the assessment show the person to be HARP eligible they will be given the choice of joining a HARP (and given code H1, with the potential for H2 or H3 based on the results of a detailed assessment). If this person is already in an HIV SNP they can remain in the HIV SNP. They will receive code H4 and, based on the results of a more in depth assessment, possibly qualify for HCBS services under codes H5 or H6. Code H9 - HARP eligible- pending enrollment- This person has been determined to be categorically eligible for a HARP. They will be given the option of moving to a HARP (where they will be given code H1, with the potential for H2 or H3 based on the results of a detailed assessment). If this person were already in an HIV SNP they would not have been given code H9, but rather code H4. They can choose to remain in the HIV SNP or move to a HARP. If they remain in the HIV SNP they could potentially, based on the results of a more in depth assessment, qualify for HCBS services under codes H5 or H6

15 How does someone receive Adult Behavioral Health HCBS services? The Managed Care Technical Assistance Center of New York

16 HARP ELIGIBLE ON DOH LIST ALREADY ENROLLED IN A HARP/HIV SNP PLAN & HEALTH HOME A HH Care Manager Conducts HCBS eligibility assessment 1 If eligible, HH Care Manager conducts Full HCBS assessment 2 B In collaboration with member, and in consultation with providers as necessary, HH Care Manager develops fully integrated Plan of Care (POC) that includes physical and behavioral health services, and recommended HCBS including the scope, duration, and frequency of HCBS; and Selected In-Network Providers 3 HH care manager consults with HCBS providers who recommend scope, duration, and frequency for HCBS. HH care manager completes POC. C HH Care Manager forwards fully integrated POC to MCO for approval of all physical health services, behavioral health services, and HCBS in the fully integrated Plan of Care(POC). MCO works collaboratively with HH care manager and member to finalize an approved Plan of Care D HH care manager ensures member is referred to services listed in POC E HH care manager monitors POC; ensures that member is getting HCBS reflected in POC; revises POC when necessary incorporating member input and choice. When POC revised MCO review is required, loop to box C 1 Key: The Eligibility Assessment can be done telephonically or face-to-face 2 HCBS Eligibility Assessment= subset The HCBS full assessment must be done face to face. Eligibility and Full of questions from NYS Community Assessments can be done in one face-to-face meeting if desired 3 Mental Health Assessment and other POCs that include recommended Home & Community Based Services (HCBS) HCBS eligibility questions must meet Centers for Medicare & Medicaid requirements and will include scope, Full Assessment= NYS Community duration and frequency of HCBS; members must be given a choice of at least 2 HCBS Mental Health Assessment to help providers from the MCO s network and there must be documentation in the POC that determine array of HCBS choice was given to the member

17 Step B B In collaboration with member, and in consultation with providers as necessary, HH Care Manager develops fully integrated Plan of Care (POC) that includes physical and behavioral health services, and recommended HCBS including the scope, duration, and frequency of HCBS; and Selected In-Network Providers 3 HH care manager consults with HCBS providers who recommend scope, duration, and frequency for HCBS. HH care manager completes POC. B.1. Health Home Care Manager refers member to Adult BH HCBS Provider for consultation B.2. Adult BH HCBS Provider conducts HCBS specific assessment and determines scope, duration and frequency B.3. Care Manager incorporates scope, duration and frequency in POC

18 Step C C HH Care Manager forwards fully integrated POC to MCO for approval of all physical health services, behavioral health services, and HCBS in the fully integrated Plan of Care (POC). MCO works collaboratively with HH care manager and member to finalize an approved Plan of Care The authorization and payment process are separate and apart from the POC process for the state plan services such as physical health services and behavioral health services.

19 HARP ELIGIBLE ON DOH LIST ALREADY ENROLLED IN A HARP/HIV SNP PLAN & CHOOSES NOT TO ENROLL IN A HEALTH HOME A The MCO contracts with a HH or other statedesignated entity to complete BH HCBS assessments and develop Plans of Care (POC) for individuals who choose not to enroll in a Health Home (HH). Care Manager conducts the BH HCBS eligibility assessment 1 If eligible, HH Care Manager conducts Full BH HCBS assessment 2 B The MCO also contracts with the HH or other state-designated entity to develop the BH HCBS Plan of Care (POC). In collaboration with member, care manager consults with HCBS providers who recommend scope, duration, and frequency for BH HCBS. Care manager completes POC. C Care Manager forwards HCBS POC to MCO. MCO is responsible for non- BH HCBS components of the fully integrated POC and for providing care coordination for the implementation of the individual s full POC, including BH HCBS 1 The Eligibility Assessment can be done telephonically or face-to-face 2 The HCBS full assessment must be done face to face. Eligibility and Full Assessments can be done in one face-to-face meeting if desired 3 POCs that include recommended Behavioral Health Home & Community Based Services (BH HCBS) must meet Centers for Medicare & Medicaid requirements and will include scope, duration and frequency of BH HCBS; members must be given a choice of at least 2 BH HCBS providers from the MCO s network and there must be documentation in the POC that choice was given to the member Key: BH HCBS Eligibility Assessment= subset of questions from NYS Community Mental Health Assessment and other HCBS eligibility questions Full Assessment= NYS Community Mental Health Assessment to help determine array of BH HCBS

20 Step B B The MCO also contracts with the HH or other state-designated entity to develop the BH HCBS Plan of Care (POC). In collaboration with member, care manager consults with HCBS providers who recommend scope, duration, and frequency for BH HCBS. Care manager completes POC. B.1. Health Home Care Manager refers member to Adult BH HCBS Provider B.2. Adult BH HCBS Provider conducts HCBS specific assessment and determines scope, duration and frequency B.3. Care Manager incorporates scope, duration and frequency in POC

21 Step C C Care Manager forwards HCBS POC to MCO. MCO is responsible for non-bh HCBS components of the fully integrated POC and for providing care coordination for the implementation of the individual s full POC, including BH HCBS The authorization and payment process are separate and apart from the POC process for the state plan services such as physical health services and behavioral health services.

22 Report: Clinical Assessment Protocols (CAPs) and Scales The Managed Care Technical Assistance Center of New York

23 CAPs are based on: Best practices International collaboration with experts Scientific analysis to define the components of CAP triggers *Developed by UAS-NY Team for Online Course

24 Support recovery principles Promote collaboration in decision making Engage support networks Build on the person s strengths Utilizes assessment information to guide care Adapts to person s level of current level of functioning *Developed by UAS-NY Team for Online Course

25 Safety Harm to Others Suicidality and Self-Harm Self-Care Social Life Social Relationships Informal Support Interpersonal Conflict Traumatic Life Events Criminal Activity Economic Issues Personal Finances Education and Employment Autonomy Re-hospitalization Health Promotion Smoking Substance Use Weight Management Sleep Disturbance Pain Falls *Developed by UAS-NY Team for Online Course

26 Health Homes and Care Management Agencies should continue using their currently established policies and procedures in dealing with high risk situations and/or members. It is recommended that Health Homes and Care Management Agencies review CAPs and Scales triggers and incorporate them into the established policies and procedures.

27 The CAPs: are based on best practices and expert collaboration use the Community Mental Health Assessment to identify the client s current life situation focus on facilitating improvement, reducing risk for further decline provide information for care planning promotes recovery empowering clients to make meaningful choices facilitate sharing information with others towards supporting the client goals *Developed by UAS-NY Team for Online Course

28 Complete the full NYS Community Mental Health Assessment, review the summary and confirm which of the 9 safety/functional domains in our NYS eligibility algorithm the person has moderate or extensive needs. Then move to the POC template and identify goals, strengths, and preferences. The care manager should work with the recipient to ensure that goals and preferences take into account the safety/functional needs identified as moderate or extensive. Identify specific Adult BH HCBS and/or State Plan Services that address the individual s goals, preferences, strengths, and needs.

29 Overview The Managed Care Technical Assistance Center of New York

30 Primary Care: Health Home Care Manager should also include physical health services as part of their integrated Plan of Care development confirming primary care physician needs and other physical health needs that individual might identify.

31 Mobile Clinic, Outpatient Clinic, ACT, CDT, PROS and Partial Hospitalization Safety Autonomy Social (Except for Mobile Clinic) Health Promotion Economy (Except for Mobile and Clinic, and Partial Hospitalization) Peer, Mobile Outreach, Clubhouse, Bridger, and IPRT Social Economy (Except for Mobile Outreach and Bridger) Health Promotion Autonomy (Except for Peer and IPRT) ACE and SE Economy

32 Outpatient Clinic, OTP, Detox Services, Residential Treatment Safety (Except for Residential Treatment) Social Autonomy Health Promotion (Except for Detox Services) Economy (Except for Detox Services, Outpatient Clinic) Harm Reduction, Recovery, Self Help Social Health Promotion Safety (Except for Recovery and Self Help) Autonomy (Except for Recovery and Self Help) Economy (Except for Harm Reduction and Self Help)

33 Rehabilitation, Peer, Family, Habilitation Social Economy Autonomy Health Promotion Employment and Education Economy CPST, Crisis/Respite Safety Autonomy Health Promotion

34 Check-list The Managed Care Technical Assistance Center of New York

35 POC Requirements/Characteristics Y/N POC development process is person-centered and reflects individual/family/caregiver preferences and support for self-management POC is written in plain language and in a manner that is accessible to individuals with disabilities and persons who are limited English proficient POC provides necessary information and support to ensure that the individual directs the process to the maximum extent possible and is enabled to make informed choices and decisions POC reflects cultural considerations of individual POC is integrated (i.e., addresses medical, behavioral health & social service needs) POC is accessible to individual and their families/caregivers POC is accessible to interdisciplinary team of providers POC indicates that the individual was given informed choice of providers among MCO's network providers and regarding the services and supports the individual receives

36 POC Requirements/Characteristics Y/N POC records alternative HCBS settings considered by individual (e.g., if the individual agrees to receiving psychosocial rehab, the POC must document that the individual was offered different settings to receive that service) POC includes strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants POC is developed in a way that meets conflict-free case management requirements (i.e., providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management or develop the POC, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop the POC in a geographic area also provides HCBS; in these cases, the State must devise conflict of interest protections including separation of entity and provider functions within provider entities, which must be approved by CMS; individuals must be provided with a clear and accessible alternative dispute resolution process) POC meetings occur at times and locations of convenience to individual POC includes method for individual to request updates to POC as needed POC is periodically reassessed and updated in a timely manner

37 Template/Required Elements The Managed Care Technical Assistance Center of New York

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52 Abuse, Neglect, Exploitation Physical Abuse: Non-accidental contact which causes or potentially causes physical pain or harm Psychological Abuse: Includes any verbal or nonverbal conduct that is intended to cause emotional distress Sexual Abuse: Any unwanted sexual contact Neglect: Any action, inaction or lack of attention that results in or is likely to result in physical injury; serious or protracted impairment of the physical, mental or emotional condition of an individual Exploitation: The illegal or improper use of an individual s funds, property, or assets by another individual. Examples include, but are not limited to, cashing an individual s checks without authorization or permission; forging an individual s signature; misusing or stealing an individuals money or possessions; coercing or deceiving an individual into signing any document (e.g. contracts or will); and the improper use of guardianship, conservatorship or power of attorney I understand what abuse, neglect and exploitation mean. If I believe I am at risk of harm from or experience abuse, neglect, or exploitation, I know that I should contact: Name: Phone: Location if at home if in the community

53 Documentation of results of the Adult BH Home and Community Based Services (Adult BH HCBS) eligibility screen (e.g., Not Eligible, Eligible for Tier 1 Adult BH HCBS-only, Eligible for Tier 1 and Tier 2 Adult BH HCBS) For individuals eligible to receive Adult BH HCBS, a summary of the NYS Community Mental Health Assessment; and For individuals eligible to receive Adult BH HCBS, recommended Adult BH HCBS that target the individual s identified goals, preferences, and needs

54 HH care managers are responsible for completing the NYS Behavioral Health Home and Community Based Services (BH HCBS) Plan for Transportation Grid (Grid) based on the services in the POC The Grid is only to be filled out if the individual requires Non-Medical Transportation There are two types of Non-Medical Transportation that would be included in this Grid: Trips to and from BH HCBS that are included in the POC Trips to and from non-hcbs destinations (e.g. job interview) that are specifically tied to a goal in the individuals POC The care manager will send the completed Grid to the MCO along with the POC. The MCO will be responsible for forwarding the Grid once the POC is approved to the transportation manager that will coordinate the Non-Medical Transportation the same way that they coordinate transportation for other Medicaid covered transportation Guidance for BH HCBS Non-Medical Transportation Services for Adults in HARPs and HARP Eligibles in HIV SNPs can be found at

55 1. Participant Information Participant Name: DOB: Care Management Program: Medicaid ID: Date of Plan: Address City County Zip code 2. MCO Information MCO Telephone Fax County Address City State Zip code 3. Transportation Provider Information Transportation Provider NPI Telephone Fax County Address City State Zip code Transportation Provider NPI Telephone Fax County Address City State Zip code Transportation Provider NPI Telephone Fax County Address City State Zip code 4. Non-Medical Transportation Goal (from Plan of Care) BH HCBS or Specific Activity/ Support/ Task Type of Transportation Service Needed Trip Destination/ Location Start Date/ End Date Frequency Non- HCBS Trip?* Y / N Y / N Y / N Date Completed By Telephone Fax *Non-HCBS trips are subject to the $2,000 per year per participant cap for Non-Medical Transportation. Trips to BH HCBS and trips using public transportation will not apply to the cost cap.

56 In collaboration with MCOs and Adult BH HCBS providers, the Health Home should develop a communication plan to share the Plan of Care information.

57 Work Flow Webinar Mental Health and Substance Use Disorder Program/Services Overview for HH Care Managers Plan of Care Trainings Webinars for Care Managers

58 @CTACNY