October 20th, The Managed Care Technical Assistance Center of New York

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1 October 20th, 2015 The Managed Care Technical Assistance Center of New York

2 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.

3 Who is MCTAC?

4 MCTAC Partners

5 Adult BH HCBS Overview

6 Rehabilitation Psychosocial Rehabilitation Community Psychiatric Support and Treatment (CPST) Habilitation Crisis Respite Short-Term Crisis Respite Intensive Crisis Respite Educational Support Services Individual Employment Support Services Prevocational Transitional Employment Support Intensive Employment Support On-going Supported Employment Peer Supports Family Support and Training Non Medical Transportation Self Directed Services Pilot (anticipated start date July of 2016)

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8 HARP-enrolled Need HARP Specific Diagram

9 Adult BH HCBS Approved Settings Still Under Review Adult Residential Not Meeting CMS Standard for Community Setting OMH Supported Housing Independent Community Housing 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 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

10 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

11 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.

12 Respite staff should coordinate with HH care coordinators and MCOs to assist with the housing process (brokering enrollment in Health Homes, identifying housing readiness skills, etc.) and should focus care and discharge planning on moving the housing process along as they are able, but will not be expected or required to find housing or to hold recipients in Respite until housing is available. If someone enters a Respite program from a shelter, it is appropriate to discharge them back to a shelter If someone enters a Respite program from the street, it is strongly recommended that client be discharged to a shelter Providers should develop policies and procedures and recipient consent and orientation processes to address these points

13 State Identified HARP Enrolled 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 Available on EPACES

14 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.).

15 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.

16 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

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

18 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 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 Home & Community Based Services (HCBS) must meet Centers for Medicare & Medicaid requirements and will include scope, duration and frequency of HCBS; members must be given a choice of at least 2 HCBS providers from the MCO s network and there must be documentation in the POC that choice was given to the member Key: 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 HCBS

19 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

20 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.

21 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

22 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

23 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.

24 Plan of care is reassessed at least annually, and more frequently when warranted by a significant change in the member s medical and/or behavioral health condition or a significant change in their status such as hospitalization, loss of housing, or successfully completing a goal. Individual receiving Adult BH HCBS or any provider including Adult BH HCBS Provider and/or Managed Care Organization can initiate the Update to Plan by communicating and informing Health Home Care Manager. Care Manager will determine whether a new assessment is needed.

25 All individuals who meet the HARP targeting criteria will be offered choice of: HARP Enrollment and Plan Selection Health Home Enrollment Use of HCBS if eligible HARP enrollees shall be provided with a choice of providers from among all of the MCO s network providers of a particular service. With respect to conflict-free care management requirements for Health Homes: To promote and ensure integrated care for the best interest of the client, it is possible that an individual may receive care management and direct care services from the same entity, however, in these instances the care management and direct service components will be under different administrative/ supervisory structures. There will be utilization management and quality oversight by the Managed Care Plans for Medicaid services. There are appeal, grievance, fair hearing, and beneficiary complaint processes in place for both Managed Care and Health Home services.

26 Co-Mingling Not Allowed Space Use OASAS & OMH There is nothing prohibiting an OMH or OASAS outpatient licensed provider from allowing an HCBS service to be provided out of their licensed space, so long as such services do not take away from the resources that the licensed program is licensed/funded by OASAS or OMH to provide Staff Sharing Allowed. Staff time must be allocated and meet all regulatory requirements Group Services Not Allowed except for PSR & Family Support Services cannot be provided telephonically

27 HCBS services will be subject to utilization caps at the recipient level that apply on a rolling basis (any 12 month period). These limits will fall into three categories: 1. Tier 1 HCBS services will be limited to $8,000 as a group. There will also be a 25% corridor on this threshold that will allow plans to go up to $10,000 without a disallowance. 2. There will also be an overall cap of $16,000 on HCBS services (Tier 1 and Tier 2 combined). There will also be a 25% corridor on this threshold that will allow plans to go up to $20,000 without a disallowance. 3. Both cap 1 and cap 2 are exclusive of crisis respite. The two crisis respite services are limited within their own individual caps (7 days per episode, 21 days per year). If a Plan anticipates they will exceed any limit for clinical reasons they should contact the HARP medical director from either OMH or OASAS and get approval for a specific dollar increase above the $10,000 effective limit.

28 HCBS/State Plan Services Allowable Billing Combinations of State Plan and HCBS Clinic/OLP ACT PROS IPRT/CDT Partial Hospital* PSR YES YES CPST YES/NO YES Habilitation YES YES YES YES Family Support and Training YES YES YES Education Support Services YES YES YES YES Peer Support Services YES YES YES YES Employment Services YES YES YES *If a participant is admitted into a Partial Hospital program, their HCBS payments will be suspended so that their services will not be terminated. ** All HARP Members are eligible for Crisis Respite Services

29 HCBS Combinations Allowable Billing Combinations of HCBS and HCBS PSR CPST Residential Support Service Family Support and Training Education Support Services Peer Support Services Employment Services PSR* YES YES YES YES YES YES CPST YES YES YES YES YES YES Habilitation* YES YES YES YES YES YES Family Support and Training YES YES YES YES YES YES Education Support Services YES YES YES YES YES YES Peer Support Services YES YES YES YES YES YES Employment Services YES YES YES YES YES YES * PSR and Habilitation may only be provided at the same time by the same agency. ** All HARP Members are eligible for Crisis Respite Services

30 Adult BH HCBS Service Specific Assessment Encounter Note Service Plan Discharge Plans It is recommended that HCBS providers have a copy of the Plan of Care and NYS Community Mental Health Assessment

31 Encounter Note: Ø Name of consumer Ø Type of service provided Ø Date of service provided Ø Location of service Ø Duration of service, including start and end times Ø Description of interventions to meet Plan of Care goals Ø Outcome (s) or Progress made toward goal achievement Ø Follow up/ next steps Ø Your name, qualifications, signature and date

32 Quality Assurance reviews and claims audits will be conducted by NYS or its designee, including Local Government Units, to ensure providers comply with the rules, regulations, and standards of the program, and may be conducted without prior notice. Ø The Quality Assurance reviews will focus on program aspects, but may include technical requirements such as billing, claims, and other Medicaid program requirements. Ø Managed care plans may also be developing protocols to oversee the provision of these services in their provider networks.

33 Providers who are interested in becoming a new designated Adult BH HCBS provider or changing their existing designation status by: Adding New Adult BH HCBS Removing Adult BH HCBS Inactive Status Should notify the state by ing at omh.sm.co.hcbs-application@omh.ny.gov Providers should also inform Managed Care Organizations of any changes to their HCBS designation.

34 All HCBS providers will need to meet CE requirements. In addition, specific HCBS services might have additional educational and/ or certification requirements. Further guidance will be forthcoming.

35 Providers will need to complete the following preemployment/background checks on all HCBS staff: The Staff Exclusion List (SEL) The Justice Center s Criminal Background Check System (which includes fingerprinting) The Statewide Central Register for Child Abuse and Maltreatment (SCR) Managed Care Organizations will complete the following reviews: (providers might be required to complete the following reviews as well) Social Security Death Master File Medicaid Exclusion List

36 10/26 -- Crisis Respite 10/27 Employment Education 10/28 -- Family Support 11/2 Peer Supports 11/6 Family Support 11/9 Peer Supports 11/13 Hab/Rehab/CPST 11/16 Hab/Rehab/CPST TBD (in-person or web-based) -- Non-Medical Transport

37 @CTACNY