HealthChoices Program Overview Presented by: Kellie Wayda, MSW, LSW Director of Western Operations Office of Mental Health and Substance Abuse Services 7/20/2018 1
Agenda Managed Care Journey in PA HealthChoices Program: IN PARTICULAR BH-HC Questions 7/20/2018 2
Managed Care Journey Prior to managed care, Pennsylvania delivered health care serves to Medicaid beneficiaries using a fee-for-service (FFS) only model. Pennsylvania began testing managed care, on a voluntary basis in certain counties as early as 1972. Managed care was expanded over the years and the HealthChoices (HC) program was officially introduced in 1997: Initially offered on a voluntary basis to Medical Assistance (MA) eligible By 2013, HC was a statewide mandatory managed care program covering both PH and BH benefits for MA eligible. In 2015, Medicaid expansion increased number of eligible adults receiving services through the HC program. 7/20/2018 3
HealthChoices Program Overview In PA Behavioral Health Services are carved out from physical health Services Three primary goals: Improve access to health care services for MA recipients. Improve the quality of care available to MA recipients. Stabilize Pennsylvania's MA spending. HC is jointly funded by the federal and state government, but implemented and administered by the commonwealth s Department of Human Services (DHS). 7/20/2018 4
HC Program Overview BH-HC overview more specific Pennsylvania s Office of Mental Health and Substance Abuse Services (OMHSAS) has oversight of the BH-HC. As of January 2018, over 2.6 million people were enrolled in HC-BH. FY 2018-19 funding is projected to be $3.9 billion. 7/20/2018 5
HC Program State Plan Eligible Services Clozaril Support D&A Methadone Maintenance D&A Outpatient Inpatient Psychiatric Inpatient D&A MH Crisis Intervention MH Outpatient MH Partial Hospitalization Certified Peer Support Targeted Case Management (ICM, RC, Blended) Laboratory and Diagnostic Services Smoking Cessation Counseling Services ER evaluations for voluntary and involuntary commitments 7/20/2018 6
HC In Lieu of Services Non-hospital D&A Detox and Rehabilitation Certified Recovery Specialist Halfway House Psychiatric Rehabilitation Services Mobile Medication Licensed Psychologist, LSW, LPC Assertive Community Treatment Teams Other 7/20/2018 7
Behavioral Health Services All CHC participants will be covered by BH managed care through the existing behavioral health managed care organizations (BH-MCOs). This is a change for Aging Waiver participants and nursing facility residents. 7/20/2018 8
Behavioral Health Services NURSING FACILITIES To assure all individuals with mental illness who reside in, or apply for admission to, Medicaid-certified nursing facilities and are in need of the services provided by the facility receive services appropriate to their needs. Nursing Home Pre-Admission Screening and Resident Review Requirements related to mental health services: OMHSAS-16-11 Bulletin Outlines requirements, processes, and responsibilities 7/20/2018 9
Behavioral Health Services SPECIALIZED SERVICES Mental health services beyond those that a nursing facility typically provides which is specified in an individualized plan of care that is developed and supervised by an interdisciplinary team. Services that are of a higher intensity and frequency than other mental health services which are provided by the nursing facility. Examples: partial hospitalization, psychiatric outpatient clinic, mental health crisis intervention, mobile mental health treatment, peer support services, mental health targeted case management 7/20/2018 10
HC Program Delivery HC PH and LTSS service/ benefits are managed by PH-MCOs and CHC DHS contracts directly with PH-MCOs and CHCs through competitive bid process. MA eligibles are: Offered a choice of PH-MCO and CHC. Offered a choice of Primary Care Physician (PCP). Eligible to receive covered services through the selected PH-MCO or CHC. 7/20/2018 11
HC Program Delivery BH-HC DELIVERY BH services/benefits are managed by counties or BH-MCOs: County is given the first opportunity to manage program directly (through a contract with the commonwealth) or subcontract with a BH-MCO. If county chooses not to participate or does not meet program standards, DHS will contract with BH-MCO through competitive bid process. 29 total BH contracts exist and 43 county or multicounty entities opted for the right of first opportunity. Only one BH-MCO in each county. 7/20/2018 12
HC Program Delivery Similar to PH-MCOs and CHCs, BH-MCOs establish provider networks. County (or BH-MCO) assume full risk for BH Services under managed care. MA eligibles are: Auto-enrolled in a BH-MCO based on county of residence. Offered a choice of BH providers within the BH-MCO. Eligible to receive covered services through assigned BH-MCO. 7/20/2018 13
HC Program Delivery Currently, there are five BH-MCOs that provide managed care to MA eligibles across the commonwealth. Community Behavioral Health Community Care Behavioral Health Magellan Behavioral Health PerformCare Beacon Health Options (formally Value Behavioral Heatlh) 7/20/2018 14
HC Program Delivery 7/20/2018 15
BH-HC Partnerships DHS County Behavioral Health/Human Services Primary contractor Alliance of Counties Behavioral Health MCOs Primary contractor Administrative services Subcontracted managed care partner 7/20/2018 16
Role of DHS and OMHSAS Monitor BH-MCO performance in meeting HealthChoices program standards and requirements: Monitoring team meetings Ongoing reporting requirements Quality management oversight Annual review process Further HealthChoices program development 7/20/2018 17
Role of County HealthChoices Visionary leadership to support the ongoing development of the local HealthChoices program. Integrated approach to meeting member needs. Ease of access to services Effective management of Medicaid and county funded services Joint service development to address gaps Furthering integrated care management Local oversight and management of the program. 7/20/2018 18
Role of BH-MCO Meet program standards and requirements. Perform delegated managed care functions. Be a responsive and accountable partner to counties. Bring state-of-the-art information technology used to further the aims of the program. Demonstrate fiscal accountability. Collaborate with human services, providers, and members. Cross-systems coordination. 7/20/2018 19
Role of BH-MCO Bring innovation, promote clinically competent, and recovery focused care Provide specialized care management for individuals with complex needs, including coordination of care with community-based services 7/20/2018 20
BH-MCO Critical Functions Member Education and Outreach Community Relations Customer Services Care Management Utilization Management Quality Management Outcomes Management Program Development Network Management Service Access Credentialing Contracting Training Claims Processing IT Finance 7/20/2018 21
Focus on Recovery Improving the Well-Being of the Individual and the Community Peer & Family Involvement Recovery Transformation Physical & Behavioral Health Integration Person with Lived Experience Focused Care Management Model Respecting Individual Differences Systems Integration (Children & Youth) 7/20/2018 22