4/7/2016. Provider Leadership Update. Reminder: Information and timelines are current as of the date of the presentation

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1 Provider Leadership Update The Managed Care Technical Assistance Center of New York Housekeeping: Slides are posted at MCTAC.org Questions not addressed today will be: reviewed and incorporated into future trainings and presentations added to Q&A resources when possible. Feedback forms Reminder: Information and timelines are current as of the date of the presentation 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. 1

2 CTAC & MCTAC Partners Agenda Introduction and Welcome Remarks State Presentation Vision & Goals Transition to Managed Care SPA Services & HCBS Q&A and Break Implementing Managed Care Readiness in your organization Contracting, Billing/Finance, Evaluation, Communication/Level-of-Care Change Management and Leadership Lessons Learned from Adult Transition Regional Planning Consortiums Q&A and wrap-up MCTAC Kids Leadership Team Reps Agency Staff/Reps RPCs Families Together 2

3 The Managed Care Technical Assistance Center of New York What it is and what it means for providers The Managed Care Technical Assistance Center of New York 9 Vision for Medicaid Reform It is of compelling public importance that the State conduct a fundamental restructuring of its Medicaid program to achieve measurable improvement in health outcomes, sustainable cost control and a more efficient administrative structure. Governor Andrew Cuomo (1/5/2011) EXPECTED OUTCOMES: Improved Health Status Improved Quality of Care Reduced Costs Care Management For All! 3

4 Redesigning the Delivery of Medicaid Services for Children MCTAC Sessions Held on January 27, February 11, and February 25, 2016; provided overview of key Children s Medicaid Redesign Initiatives: The State is continuing to work on the details of the Medicaid Redesign for Children The overall design includes moving benefits and populations to Medicaid Managed Care and will impact the way providers deliver services, manage their business operations, and use the tools and services they have to improve health outcomes of the Medicaid children they serve Today s training will provide background information on what Managed Care is and what providers need to be thinking about to become ready to operate in a Managed Care environment Goals of Redesigning the Delivery of Medicaid Services for Children Get children in receipt of Medicaid back on their developmental trajectory: Identify needs early Maintain the child at home with support and services Maintain the child in the community, in least restrictive settings Prevent longer term need for higher end services Focus on recovery and building resilience! Children Impacted by the Medicaid Redesign Initiative Youth diagnosed with Substance Use Disorders Children and youth diagnosed with Serious Emotional Disturbance (SED) Children and Youth served by Voluntary Foster Care Agencies Children and Youth in foster care who have experienced abuse, neglect and maltreatment, and Medically fragile children with complex conditions, requiring significant medical or technological health supports 4

5 How the Children s Medicaid Redesign will Achieve its Goals The State is continuing to work on the details of the following Key Features of the Children s Medicaid Redesign Expanding access to care management for children with chronic conditions under the Health Home program, or for children with lesser needs through Managed Care plans or other vehicles a key to integrating care planning and service provision September 2016 Creating New State Plan Services January 2017 Transitioning existing children s behavioral health benefits from feefor-service to managed care a key to integrating behavioral health and physical health - January/July 2017 Providing greater access to an aligned array of Home and Community Based Services, beginning in 2017 Shifting the voluntary foster care per diem population to managed care, January/July 2017 Principles for Serving Children in Managed Care and Health Homes Ensure managed care and care coordination networks provide comprehensive, integrated physical and behavioral health care that recognizes the unique needs of children and their families Provide care coordination and planning that is family-and-youth driven, supports a system of care that builds upon the strengths of the child and family Ensure managed care staff and systems care coordinators are trained in working with families and children with unique, complex health needs Ensure continuity of care and comprehensive transitional care from service to service (education, foster care, juvenile justice, child to adult) Principles for Serving Children in Managed Care and Health Homes (cont.) Incorporate a child/family specific assent/consent process that recognizes the legal right of a child to seek specific care without parental/guardian consent Track clinical and functional outcomes using standardized pediatric tools that are validated for the screening and assessing of children Adopt child-specific and nationally recognized measures to monitor quality and outcomes Ensure smooth transition from current care management models to Health Home, including transition plan for care management payments 5

6 The Managed Care Technical Assistance Center of New York Two Payment Systems for NYS Medicaid Services 1. Medicaid Managed Care System a managed care organization authorized by NYS receives a monthly premium from NYS Medicaid for an enrolled individual and manages the individual s care within a specific comprehensive benefit package. The Plan assumes risk, provides care management and applies utilization management methods for each member. When providers in the Plan s network (i.e., hold a contract with the Plan) provide a service to the individual, the provider bills the Plan and is paid funds from the premium. 2. Fee-for-Service Delivery System a provider is authorized by NYS to deliver a Medicaid service. If delivered to a Medicaid enrolled individual, the provider bills Medicaid through the emedny billing system. NYS pays the provider directly through emedny, for each Medicaid service delivered. Managed Care: Definition An integrated system that manages health services for an enrolled population rather than simply providing or paying for the services Services are usually delivered by providers who are contracted under a capitated payment structure or employed by the plan Value of services vs. volume of services 6

7 Managed Care: Goals Control Costs Health care costs growing faster than Gross Domestic Product (GDP) Reduce inappropriate use of services Increase competition: focus on value Improve Service Quality Improve Population Health Increase Preventive Services: Promote Health (not just treat illness) Managed Care: Key Ingredients Care management Utilization management Health management Vertical service integration and coordination Financial risk sharing with providers Managed Care: Key Components Network of providers created via contracting Prior approval required for some services. Benefits package with a defined set of covered services Contained list of covered pharmaceuticals (Formulary) Utilization review practices to manage level of care and length of stay Credentialing Outcomes & data driven decision making 7

8 Medicaid Services Transitioning from Fee-for-Service to Managed Care OMH Residential Treatment Facility (RTF) New State Plan Services (SPA) OASAS Outpatient Services OASAS Residential Rehab Newly aligned HCBS Array OMH SED Designated Clinics OMH Day Treatment Children Currently Excluded from Medicaid Managed Care Children with Third Party Health Insurance (i.e., parent has employer offered health insurance or insurance coverage through the Exchange) Children dually eligible for Medicaid and Medicare Individuals who become eligible for Medicaid only after spending down a portion of their income Youth placed in OCFS operated Juvenile Justice facilities Enrollees of Child Health Plus Eligible children served by OPWDD 1915 c waiver Eligible children served by Office for People With Developmental Disabilities (OPWDD) OPWDD Medicaid Redesign is Separate Initiative Children placed with voluntary foster care agencies (moving in) Some children can be eligible for Medicaid but be excluded from Medicaid Managed Care, and still be eligible for certain Medicaid services which would be paid out of the fee-for-service payment system. Michael Michael lives with his mother and two siblings. He is eligible for Medicaid due to the household income and is enrolled in a Medicaid Managed Care Plan. TODAY Michael s Medicaid services are paid by Medicaid Managed Care Plan, who in turn pays providers for: Dental Check Up Pediatrician Visits for well care and treatment of illness Medications Michael has additional Medicaid services paid through NYS Fee for Service Payment System: HCBS services through the OMH SED Waiver Services in an OMH designated SED clinic 2017 and Beyond Transition to MMC Michael s Medicaid services will all be paid by a Medicaid Managed Care Plan with premium dollars, directly to providers: Dental Check Up Vaccinations Testing and Treatment for Strep Throat Services in an OMH designated SED clinic Psychosocial Rehabilitation Health Home Care Coordination HCBS Skill Building HCBS Respite 8

9 Children s Medicaid State Plan Amendment - Update Six New Services: Crisis Intervention Other Licensed Practitioner Community Psychiatric Supports and Treatment (CPST) Psychosocial Rehabilitation (PSR) Family Peer Support Services Youth Peer Support Services SPA Services Require CMS Approval SPA Application in final revision stage Draft SPA Provider Manual was released on March 9, 2016 Draft SPA Provider Manual Definition of Service Components Allowable Service Modality Allowable Setting Admissions/Discharge Criteria (i.e., medical necessity) Limitations/Exclusions Agency/Supervisor/Practitioner Qualifications Training Requirements and Recommendations Recommended Staffing Ratio/Caseload Size Link to Manual on MCTAC s Website Children s SPA Provider Identification Process Anticipate an application and designation process Must hold specific types of licenses, certifications or designations from OMH, OASAS, OCFS or DOH and serve children Technical assistance will be given to those that are not already Medicaid providers The State will provide guidance on MMIS Provider enrollment for designated providers Approximately 6 months prior to launch, MCTAC will offer service specific training 9

10 The Managed Care Technical Assistance Center of New York Payment Rules Model Contract Rules Disagreements with Care Plan/Adverse Determination Plan Action Appeals External Appeal DOH complaints Provider Responsibilities Health and Behavioral Health Transition: Specific rules for Children s health and behavioral health transition Prompt Pay Law 30 day processing of clean electronic claims (45 days for paper) Written notice of reason for denied claims Insurer pays interest for late payments At least 90 days to file claims (MMC non-pars have 15 months) Untimely filing dispute resolution process Coding dispute resolution process (Article 28 hospitals only) 30 day written notice before recoupment Non-par inpatient and ER paid at FFS rate Prescriber prevails for some drug classes Transitional care coverage for new enrollees Alternate level of care 30 10

11 Plan may issue adverse determinations Notice of Action Plan clinical rationale must demonstrate Review of enrollee specific data Specific criteria not met Be sufficient to enable judgment for basis of appeal Enrollee right to appeal, external appeal and fair hearing described in notice all may be expedited Providers have appeal rights on own behalf 31 Possible next steps: Discuss alternate service options with MMCP care manager o MMCPs must arrange for services to meet care needs Request specific clinical review criteria used File appeal with MMCP; include documented support for requested service File external appeal or fair hearing Contact NYS Department of Health for issues with process, access to or quality of care 32 Enrollees have at least 60 business days to file Plan determines in: Expedited, 2 bd of all info and no more than 3 bd from appeal Standard, no later than 30 days from appeal All may be extended up to 14 days if: Plan needs more info and in member s best interest to extend Enrollee or provider requests extension Notice to enrollee and provider: Expedited verbal notice at time of decision, written in 24 hours Standard written notice within 2 business days of decision 33 11

12 Appeal conducted by clinical reviewer that doesn t work for the plan or State When plan denies service as: Not medically necessary; Experimental/investigational; or Out of network and not materially different from a service available from a network provider Enrollees have 4 months to file external appeal after receiving the plan s response to a first level appeal (final adverse determination) Plan and enrollee may jointly agree to waive internal process, file EA within 4 months of this agreement If filing expedited plan appeal, enrollee may file expedited external appeal at the same time If plan does not follow appeal process correctly, enrollee may directly file external appeal Providers have independent right to external appeal Concurrent and retrospective reviews 60 days to file Enrollees and providers may file a complaint regarding managed care plans to DOH managedcarecomplaint@health.ny.gov When filing: Identify plan and enrollee Provide all documents from/to plan Medical record not necessary Issues not within DOH jurisdiction may be referred DOH is unable to arbitrate or resolve contractual disputes in the absence of a specific governing law File prompt pay complaints with Department of Financial Services 35 Verify Medicaid managed care eligibility prior to assessment or admission Know provider contract and plan policies and procedures Obtain initial authorization, as required, from the plan and provide services according to the approved care plan for the duration of the authorization Plans are part of the patient-centered planning team. Submit full information with request to support treatment level proposed in care plan as per plan procedures 36 12

13 The Managed Care Technical Assistance Center of New York BH Network requirements include: Contracts with OMH, OASAS, OCFS, or DOH licensed, certified, or designated providers serving 5 or more Plan members for a minimum of 24 months Plans must contract for State operated BH ambulatory services Treated as Essential Community Providers Plans must network with: All Opioid Treatment programs in their region 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 38 PAYMENTS Designated plans pay FFS government rates to OMH, OASAS, OCFS, and DOH licensed or certified providers for ambulatory services for 24 months Plans must meet timely payment requirements CLAIMING Plan must be able to support BH services claim submission process. This includes training providers Plans must meet timely payment requirements Plans must support web and paper based claiming 39 13

14 Questions? Preliminary Steps and Readiness Domain Review The Managed Care Technical Assistance Center of New York Children s System Children s Health Homes: Statewide 9/1/16 New State Plan Services: Statewide 1/1/2017 Transition to Managed Care NYC/LI: 1/1/2017 Rest-of-State: 7/1/2017 Children's HCBS NYC/LI: 1/1/2017 Rest-of-State: 7/1/2017 Children in Voluntary Foster Care transition to Managed Care NYC/LI: 1/1/17 Rest-of-State: 7/1/17 14

15 September 2016 Children s Health Homes: Statewide January 2017 New SPA Services: Statewide Transition to MMC: NYC/LI HCBS: NYC/LI July 2017 Transition to MMC: Rest-of- State HCBS: Rest-of- State Rest-of-State Adult BH Managed Care Transition DSRIP OASAS Systems Transformation Adult HCBS Implementation Ongoing Post-Implementation for NYC and Rest of State Adult System The Managed Care Technical Assistance Center of New York 15

16 Exclusions and Transition Process for those carved-in Who s on First? Identifying populations served (epaces) Workflow for: Initial authorization Concurrent review HCBS Referrals Pre Admission Certification Committee (PACC) and Single Point of Access (SPOA) SPA & HCBS Designation Process Contracting, Claims Testing, and Billing Six months Take advantage of the opportunity to test claims with MCOs be ready! Innovate/Adapt: Consider how your work might need to change in order to support the outcomes required in the transformed system Training: Think about the training you will need in order to be successful in this new model and share your thoughts with your supervisor Stay Informed: Read articles and other materials given you to better understand how these changes will impact your work Get Involved: Participate in relevant trainings / agency planning sessions FIDA 16

17 It may feel complicated and confusing. but MCTAC and the State will lay it out for you! Beginning in September, 2014, MCTAC offered a tool targeting behavioral health providers to help them assess their own readiness for Managed Care and benchmark them with their fellow agencies around the state. MCTAC Readiness Assessment Domains Domain Name Label in Graphs 1 Understanding MCO Priorities & Present Managed Care Involvement MCO Priorities 2 MCO Contracting Contracting 3 Communication /Reporting (Services authorization, etc.) Communication 4 IT System Requirements IT 5 Level of Care (LOC) Criteria / Utilization Management Practices Level of Care 6 Member Services/Grievance Procedures Member Services Interface with Physical Health, Social Support and 7 Health Homes Interface Quality Management/Quality Studies/Incentive 8 Opportunities Quality 9 Finance and Billing Finance 10 Access Requirements Access Demonstrating Impact/Value (Data Management & Evaluation Capacity) Evaluation 17

18 52 Domain Average Score 7. Interface MCO Priorities Access Finance Contracting IT 3.17 TOTAL AVERAGE SCORE Level of Care Member Services Quality Communication Evaluation 2.63 Gather your transformation team Identify areas based on: Where you need the most help When capacity and knowledge is needed Why your domain specific scores were lower/higher Readiness assessment results were sent to agencies The assessment is still available for those who are interested. Please contact for more information. 18

19 Knowledge and skills (growth orientation) Each member expands his/her awareness and understanding of Medicaid Managed Care (MMC) Each member makes the best use of the resources and tools provided by the learning community to gain knowledge and develop competencies Shared Vision Each member has a shared understanding of Medicaid Managed Care Each member communicates the vision every chance he/she gets Each member engages in an honest discussion about MMC to develop a shared vision Team sees the purpose and direction of change Articulated in a minute or less Shared commitment Each member attends meetings and follows through with tasks Keeps moving forward in the face of inevitable challenges and barriers Outcome orientation Each member works to translate the vision of Medicaid Managed Care into specific and measurable improvements through qualitative and quantitative data. Leadership Perspective Committed leadership with responsibility and authority to guide the change process Involve those affected by the change Involve those expected to carry out the change in day to day activities Involves those with experience or knowledge related to the change Involve those who can provide resources to support the ongoing program development process Involves those whose values, interests, beliefs and orientation aligns with the change (champions) 19

20 3 critical areas that leaders will need to address as part of a sustainable change process: 1. Change Management 2. Quality Improvement Methodology The ongoing capacity to use data to inform decision making 3. Workforce Development New knowledge, skills and mindset It is not unusual for an organization s leadership to believe that it is engaged in promoting strategic change and for its workforce to experience it as shock change. Woodward, H. and Woodward, M.B. (1994). Navigating Through Change. NY: McGraw Hill. The Triple Aim: Enhancing patient experience Improving population health Reducing costs The Quadruple Aim (Bodenheimer & Sinsky 2014): Enhancing patient experience Improving population health Reducing costs Improving the work life of health care providers 20

21 The answers to all of the above questions must be YES if the service is to be paid by the MCO. Providers will be required to complete the contracting and credentialing process to be considered an in-network provider New Contracts vs. Established Contracts Providers with existing Managed Care Contracts may only need to execute/sign contract amendment Providers without an existing contract with an MCO will need to complete the full contracting and credentialing process State Protections Government Rates for 2 Years from implementation date 5 or more Clients MMIS & NPI Technical Assistance Contracting Series outlines contracting basics, timelines, and process Contracting Fairs provides opportunity to meet with MCO reps MCTAC s MCO Matrix Provider credentialing is a systematic approach to the collection and verification of a provider's professional qualifications. The qualifications that are reviewed and verified include relevant training, licensure, certification, and registration to practice in a health care field. Based on current implementation timeline, providers should expect to begin contracting and credentialing processes at least 6 months prior to go-live in coordination with plans. 21

22 Credentialing is important for the following reasons: To ensure quality of care for MCO members; and To avoid potential malpractice liability, if (i) an MCO accepts a provider into its network; (ii) the provider causes patient harm; and (iii) the provider should not have been included in the network based on information the MCO should have been aware of, then the MCO could be exposed to potential liability CSRA (formerly known as Computer Sciences Corporation or CSC) Regional Representatives are available to offer provider billing training on a variety of topics through numerous methods including: Individual meetings with providers to train and troubleshoot issues Group training seminars and webinars To request a meeting with a Regional Representative call emedny Call Center at MCTAC Tools MCO Matrix: interactive online tool that provides critical information necessary for providers to successfully engage with the plans. Billing/Claims: tool that contains critical information for clean claim submission with field by field detail for the UB-04/837i form, plan by plan Glossary of Terms/Top Acronyms/Managed Care Language Guide Utilization Management: tool that provides guidance around prior authorization and concurrent review practices for each plan for state ambulatory services. Credentialing: An integrated tool that provides information on required credentialing processes & documentation Chargemaster: tool to assist providers in cross walking information from services provided to the necessary billing codes. 22

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24 Evaluation & Data Data Already Exists The key is to identify it and use it to inform your processes Choose and define the outcomes of focus Capture the data and understand it so that it informs: The client The program The agency The payer Referral Sources Data must be accessible and actionable by everyone 24

25 What is Utilization Management (UM)? The process by which an MCO decides whether specific health care services or specific level of care are appropriate for coverage under an enrollee s plan Primary purpose of the program is to ensure that services are medically necessary, appropriate, and cost-effective Maintain fidelity and integrity of service provisions while meeting UM standards and requirements It s a determination of whether the service is necessary and appropriate for the patient s symptoms, diagnosis, treatment, and recovery Many MCO contract definitions of medically necessary state that services may not be provided primarily for the convenience of the patient or the provider DOH definition of Medically Necessary : Health care and services that are necessary to prevent, diagnose, manage or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person s capacity for normal activity, or threaten some significant handicap. Regional Planning Consortia (RPCs) Concept of the NYS Conference of Local Mental Hygiene Directors, visit Hot Topics for full description & map of RPC regions CLMHD & LGUs beginning start-up and staffing now Based on the premise: Transforming the BH system and how the implementation impacts the system & the people & the families served Requires a collaborative community focus and continuous, vigilant attention This is the RPC role and function RPCs-multi-stakeholder groups comprised of: Consumers Families/Youth LGU s MCOs & HARPS Adult and child services Housing providers Hospitals & primary care providers PPSs PHIPs State Agencies LDSS LDH 25

26 Calendar Outline, Tools & Resources The Managed Care Technical Assistance Center of New York Webinar Series January/February 3-part series presenting general information and outline of New York State s plan surrounding critical topics. In-Person System Transformation Update Events Offered statewide, 3-4 hour sessions including presentation by state agency children s leadership team and discussion. Target audience: executive leadership of child-serving agencies, MCO representatives, other stakeholders. Managed Care (Planned for 1/1/17 NYC/LI and 7/1/17 for Rest of State) Contracting/Credentialing Statewide, both in-person and web-based and will include workshops and contracting fairs once plans have been identified (6 months before transition) Implementation Series: Billing, UM guidelines, and credentialing after respective plan information has been released (3-4 months before transition dates) Data and Outcomes Road Map - Understanding Your Population, Key Performance Indicators, Costs and Revenue & Outcomes (offered statewide ongoing) 26

27 Contracting and Credentialing Claims Testing 6 months prior to go-live 3 months prior to go-live Billing Go Live *Timeline relies on estimation of when information from state and designated MCOs are finalized and available. SPA (Planned for 1/1/17) May/June Designation process, billing rules, high-level service-by-service overview (in-person and web-based) September In-person meetings on rates/billing codes, staffing requirements, caseloads, eligibility/medical necessity, deficit funding, EHR help October Webinars on referral process, documentation, continuing education, co-enrollment rules, exclusions, health home interaction, reporting requirements November/December Detailed overviews for each service (full-day statewide in person and web-based supplements) HCBS Delivery Preparation (Planned Implementation of 1/1/17 LI/NYC and 7/1/17 for Rest of State) July - Service definitions, provider eligibility, application/designation process Sept - Plan of care and workflow development and implementation support Oct/Nov - Rates/billing codes, staffing requirements/ caseloads, eligibility medical necessity, deficit funding, start-up funds/ EHR help Nov - Utilization management, referral process, documentation, continuing education, co-enrollment rules, exclusions, health home interaction, reporting requirements, evaluation, outcomes Dec Detailed overviews for each service 27

28 Produce and monitor payer mix report based on EPACES information and not billing setup Develop a transformation team that will meet at least once a month if not bi-weekly. The team should include all areas of agency Develop internal communication plan Review current staffing and titles to see if consistent with the transformation Access review current referral processes and see if they can be improved Financial systems Review financial system to determine if they are set up to manage managed care billing IT/EHR Review of IT/EHR systems Review Draft SPA Manual Children s Managed Care Design: htm s (please specify if kids system specific in subject line): NYSOMH Managed Care Mailbox: OMH-Managed-Care@omh.ny.gov NYS OASAS Mailbox: PICM@oasas.ny.gov NYSDOH Health Homes for Children: HHSC@health.ny.gov For questions & information related to Managed Care, SPA, and HCBS training and technical assistance: Mctac.info@nyu.edu mctac.info@nyu.edu 28