What Medicaid Managed Care and Health Homes Mean to the Child Welfare Population. August 16, 2013

Transcription

1 What Medicaid Managed Care and Health Homes Mean to the Child Welfare Population Maureen M. Corcoran President August 16, 2013 Daphne Kackloudis Saneholtz Senior Advisor Vorys Health Care Advisors, LLC

2 Two Polling Questions???? 2

3 Medicaid Handbook: Interface with Behavioral Health Services 3

4 Evolving health care environment Ohio & National Medicaid/OHT EXPANSION Eligibility Redesign Managed Care Changes Care Coordination, ICDS Minds Matter Child Welfare Health Plan esp. psych meds Behavioral Health System SPMI Health Home Service redesigns, IHBT Elevation Match Cost Containment Other inc. JJ/FCF MH/JJ Reforms Need for Inpt. BH Oct. 22 nd PCSAO Invitational Behavioral Health Leadership Summit

5 Medicaid Basics Medicaid Basics Joint federal/state program Federal parameters, some required eligibility groups and some required services Some options for state to go further Feds pay 64%, State pays 36% (Ohio FY2013) Principles of Medicaid Consistency, uniformity Ensure access to needed services Ensure recipients have free choice of provider Ensure client rights and protections 5

6 Medicaid Basics (continued) Medicaid Basics Medicaid includes the EPSDT mandate Early: Identify problems early, starting at birth Periodic: Check children s health at periodic, age- appropriate intervals Screening: Perform physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems Diagnosis: Perform diagnostic tests to follow up when a risk is identified Treatment: Treat the problems found EPSDT requires: Such services to correct or ameliorate defects and physical and mental health conditions whether or not such services are covered under the state medical assistance plan. * States have options re how to design & deliver their program *1905 (r) of the Soc.Sec.Act, 42 U.S.C. 1396d(r); Part 5, Section 5122 of the State Medicaid Manual, available at 6

7 Ohio Medicaid Expansion L L L NOTE: Subsidy for the Exchg. 100%- 400% 4 4 7

8 Medicaid Service Delivery Systems Benefit Plans & Delivery Systems Primary & Acute Care Specialty Care Fee For Service Managed Care LTC NF & ICFMR DD waivers NF waivers MSP MH/AOD Community

9 Community Medicaid BH Services Administered through ODMHAS Carved Out of MCP COMMUNITY MENTAL HEALTH SERVICES 1. Pharmacological management 2. Mental health assessment 3. Behavioral health counseling and therapy (individual & group) 4. Crisis intervention behavioral health services 5. Partial hospitalization 6. Community psychiatric supportive treatment (individual & group) ALCOHOL & DRUG ADDICTION SERVICES 1. Ambulatory medical/social detoxification services 2. Assessment services 3. Case management services 4. Crisis intervention services 5. Group counseling 6. Individual counseling 7. Intensive outpatient services 8. Drug Screening/ urinalysis 9. Medical/somatic services 10.Methadone administration services 9

10 Managed Care Polling Question???? 10

11 Managed Care Ohio has expanded to nearly 100% mandatory Platform for Ohio s Medicaid delivery system Stampede to managed care Increasing use with more vulnerable populations It s changed/matured in last 5 years TOPICS: Fundamentals, Tools, Features, Elements, Characteristics Care Management 11

12 Managed Care Originally used widely in Medicaid with healthy moms and kids. Managed care meets Behavioral health Aging and long term services and supports Child welfare Men Are from Mars, Women Are from Venus CROSS CULTURAL 12

13 Managed Care Fundamentals or tools Federal definition & authorized use Benefit package Carve in/carve out, Ohio residual benefit Medical necessity and EPSDT Emphasis on prevention Contracting with providers, external to the MCP Risk and actuarial soundness 13

14 Managed Care Tools (continued) Fundamentals or tools Prior authorization requirements CP%20Comparison%20Sheet-%20OAHP.pdf 14

15 Managed Care Tools (continued) Fundamentals or tools Network requirements/access Credentialing: URAC, NCQA, others Process: Procurement Readiness review Ongoing Monitoring: data reporting, review of complaints/denials etc. 15

16 Managed Care Tools (continued) Health Information Technology Analytics Patient Profile Provider Access Portal Clinical Practice Registries Exchange of Data, for example with the health homes 16

17 Managed Care vs. FFS Reimbursement rewards value, not volume Accountability for performance measurement, inc. 2% of payments at risk Accountable medical home, rather than provider centered care Administrative efficiencies, inc. consolidated to 3 regions with 5 plans in each Encourages innovation and new payment models Care management and cost control are expectations 17

18 Benefits of Managed Care for Consumer Point of accountability or assistance to navigate/get needs addressed Benefit of care management for those with complex conditions Prevention emphasis-weight loss, smoking cessation etc. Improved coordination of care, tighter network, less ability to hop from one provider to another Lock in programs Oversight of providers, less likelihood of over prescribing Some additional flexibility in benefits for the consumer, such as transportation. 18

19 Ohio s Managed Care Policy Who is in Mandatory Medicaid Managed Care today? Most Adults: EXCEPT those in an institution, on spend down, on a waiver, or who are dually eligible for Medicaid and Medicare Most Children/Youth, including disabled kids (ABD) with the following exceptions: NOT ABD kids who are in an institution, on spend down, on a waiver, or who are dually eligible for Medicaid and Medicare NOT ABD kids receiving BCMH who have CF, cancer or hemophilia-1 year delay on inclusion NOT youth under 19 years of age who are in foster care or other out of home care placement or receiving foster care or adoption assistance (any Medicaid category) 19

20 X X July 1, 2013 X New contracts, including ~ 37,000 Xl disabled children went into effect 20

21 What is Care Management in Managed Care? Managed care assumes coordination of all health care services Carve Out issue Telephonic care management-various team models Disease management programs Utilization management Call centers, Nurse lines Occasional use of home health care services when face to face required Venus 21

22 Changes to Ohio MCP Care Management Requirements Basic care management requirements-program that coordinates and monitors care for enrollees with complex needs. Identify, assess & develop plan of care Telephonic care management (<15% of total) Since Oct MCPs have > care management requirements for top 1% of each MCP s population deemed high-risk. Ratio of 1 to 25. Includes quarterly face-to-face visits Disease management programs 22

23 Why? Wouldn t know til they got a bill. Developed a very good working relationship with 1 then 2 MCPs. Preferential treatment. Data Foster parent picks one of two MCPs. Access to Docs: Managed Care Child Welfare Lucas County Children s Services Docs can be paid more than FFS Medicaid & billing easier Relies on docs to do the prior auth LCCS calls MCP for overrides, out of plan services, help with extra services 23

24 Managed Care Child Welfare Lucas County Children s Services LCCS HCF assigned every kid, 4 nurses. Med Dir Any/all changes made by LCCS Health Care Facilitator Every visit to doc-take 2 forms Consent for treatment Health visit form with SSE HCF & foster parent f/u, trouble shoot if needed HCF manages the communication with the MCP, or pulls the kid out/to FFS Out of county placements Combination of SACWIS & own system Psych med monitoring 24

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26 Managed Care Polling Question???? 26

27 Targeted attention to physical and behavioral issues that will improve the quality of care and reduce cost Care coordination INTEGRATION Why Health Homes? & What are they? 27

28 The Integration Mandate: Example Hospital Admissions

29 Health Home Concept Builds on the Patient Centered Medical Home (PCMH) Building linkages to community, social supports and recovery services Coordinating care across medical, behavioral and long term care Focusing on patients with multiple chronic and complex conditions Focus on outcomes, improved experience of care and quality of care. 29

30 Health Home Basics 2703 of ACA Health Home for Enrollees with Chronic Conditions SMDL # /16/10 Population Criteria At least two chronic conditions, One chronic condition and at risk for another, or One serious and persistent mental health condition. 30

31 Six Health Home Services 1. Comprehensive care management 2. Care coordination and health promotion 3. Comprehensive transitional care from inpatient to other settings, including appropriate follow-up 4. Individual and family support, including authorized representatives 5. Referral to community and social support services 6. Use of health information technology to link services These six qualify for 90% federal match. 31

32 Timeline re: HH Implementation June 2012: LOIs, Rules & SPA submitted July 2012: HH applications accepted August 2012: HHs selected September 2012: SPA approved October 2012: Phase 1 began July 2013: ODMHAS narrows eligibility criteria and changes rates; rule changes August 15: ODMHAS & OMA announce more changes October 2013: Phase 2 to begin CANCELLED 32

33 Then Target population: HH criteria + Adults & Kids Provider type plus specifics: CBHC Provider Geography: Regional & phase in statewide Reimbursement Rate: Doesn t presume the model by fixing the rate up front (Provider specific case rate) Role of the Managed Care Plan: (Coordinate) 33

34 Then and Now Target population: HH criteria + Adults & Kids Provider type plus specifics: CBHC Provider Geography: Regional & phase in statewide Reimbursement Rate: Doesn t presume the model by fixing the rate up front (Provider specific case rate) Role of the Managed Care Plan: (Coordinate) Target population: HH criteria + Adults & Kids + Narrowing, esp. kids Provider type plus specifics: CBHC Provider Geography: Start with 5 counties; expand statewide Reimbursement Rate: Two different monthly case rates - $215 for lower acuity, $315 for higher acuity Role of the Managed Care Plan: (Coordinate) 34

35 Health Home Population Criteria - SED 17 years of age or younger; OR age and enrolled in high school, DYS or children services custody; OR when it is otherwise developmentally/clinically indicated Any DSM-IV TR diagnoses EXCEPT developmental disorders, SUD, V codes Assessment of impaired functioning at age appropriate levels and difficulty with age appropriate role performance with a GAF score below 60 Duration of the mental health disorder has persisted or is expected to be present for 6 months or longer NARROWING OF ELIGIBILITY CRITERIA 35

36 Rollout Phase 1 = Adams, Butler, Scioto, Lawrence, Lucas (10/1/12) Phase 1 counties will continue to operate under the existing requirements, for the time being Phase 2 = rest of the state (10/1/13)-DELAYED 36

37 Child Welfare Issues Can youth in foster care participate in a health home? Yes, if they meet the criteria and the client/parent/guardian chooses the health home What is the issue with CPST? CPST is backbone of many BH services, including treatment foster care All CPST activities have been included in the definition of health home services CPST or Health Home but not BOTH ODMHAS acknowledges the problem, no solution yet 37

38 CPST IHBT & ACT HH Payment: Other Important Intersections Partial/Day Treatment, Family Counseling Other Evidence Based Practices for children/youth 38

39 The Integration Mandate: Example Mark 18yo Treatment Foster Care, XYZ County JFS Custody Current Diagnosis Axis 1 Physical abuse of child Depression D/O NOS, R/O Adjustment D/O ADHD NOS R/O Phonological D/O Axis 2: Moderate MR Axis 3: Insulin dependent DM type 1 Having DM, foster care placement Meds Focalin XR & Novalog & Lantis 20 units of CPST during 4 week timeperiod

40 Essence of Integrated Care 1. Comprehensive care management 2. Care coordination and health promotion 3. Comprehensive transitional care from inpatient to other settings, including appropriate follow-up 4. Individual and family support, including authorized representatives 5. Referral to community and social support services 6. Use of health information technology to link services 40

41 Polling Question???? THANKS FOR PARTICIPATING TODAY-WE HOPE IT WAS HELPFUL! 41

42 About Vorys Health Care Advisors Vorys Health Care Advisors, LLC helps health care providers, business decision makers and professional associations to achieve their objectives in a constantly changing governmental and business health care environment and to assist them in making well informed, strategic and tactical decisions tailored to their individual goals, needs and aspirations. Contact Information Maureen Corcoran, MSN, MBA mmcorcoran@voryshcadvisors.com Daphne K. Saneholtz, JD dksaneholtz@voryshcadvisors.com Vorys Health Care Advisors 52 E.Gay St Columbus OH