OMH Children's HCBS Waiver 1915c Changes IMPLEMENTATION MEETING SERIES JUNE 15, 2017
Housekeeping Slides will be distributed electronically and posted to the CTAC website following the meeting series A Q&A resource will be developed and distributed Web-based support will be offered this summer to review ongoing implementation and additional questions Reminder: All information is current and accurate as of the date of presentation 2
Schedule of Offerings Buffalo: Thursday, May 25th, 9:30 am - 12:30 PM Syracuse: Wednesday, May 31st, 9:30 AM - 12:30 PM Lake George: Thursday, June 1st, 9:30 AM - 12:30 PM New York City: Monday, June 5th, 10 AM - 1 PM Poughkeepsie: Thursday, June 8th, 1:30-4:30 PM 3
Today s Agenda I. Administrative Concerns II. Programmatic Concerns III. Expanding Populations and Services IV.Preparing for the Future 4
Presenters NYS Office of Mental Health: Meredith Ray-LaBatt Joyce Billetts Shannon Fortran Steve Vroman Community Technical Assistance Center of New York: Boris Vilgorin Andrew Cleek Yvette Kelly Dan Ferris Caitlin Cronin Meg Baier 5
How Did We Get Here? AND WHAT DO WE DO NOW?
Overview of Shift Why are these changes occurring? Renewal application to CMS of Waiver authority CMS requirements based on changes in federal policies Alignment and preparation for future initiatives (health homes, Medicaid managed care, Medicaid redesign) What have we heard? Addressing your concerns: Impact on families Impact on staff and program model Fiscal viability Managing the multitude of concurrent system changes 7
How Can Agencies Prepare? I. Administrative Concerns i. Organizational Restructuring ii. Staffing Implications iii. Billing, Rates, and Limitations iv. Fiscal Implications 8
Organizational Changes
Organizational Restructuring Conflict Free Case Management (CFCM): The same agency but NOT the same individual can provide unbundled services. ICC agencies are required to: Create administrative and supervisory firewalls between care coordination and HCBS Wavier services/functions (complete separation of care coordination from direct service) Discontinue ICC from providing any other HCBS service to those they are providing care coordination Ensure family choice of HCBS service provider and right to change service provider if desired or dissatisfied Inform child/family of right to file complaint and/or grievance 10
Example Organizational Chart Executive Director/CEO Cabinet or Executive Level Manager/ Program Director Cabinet or Executive Level Manager/ ProgramDirector Cabinet or Executive Level Manager/ Program Director Care Coordinator Supervisor HCBS Wavier Services Supervisor Quality Assurance and Quality Management Supervisors Care Coordiantors HCBS Wavier Service Provider Staff Quality Management Staff 11
Aligning Agency Services Care Coordination Direct Services HCBS State Plan Services Health Homes IIHS Clinic ICC OMH HCBS Waiver CRS PROS B2H HCIA Respite Day Treatment Non-Medicaid Former TCM FPSS New Services: YPA, Pre-Voc., Supported Employment 12
Programmatic Changes Staffing Implications Unbundling/CFCM Increase in ICC case ratios Repurposing/reassignment of staff Slots ICC Now ICC Future Reassigned Staff 168 28 19 9 54 9 6 3 18 3 2 1 13
Staffing Considerations Multiple questions regarding whether ICC can also be part time IIHS and/or CR for children for who they do not coordinate care. This requires very clear FTE separations to ensure adherence to CFCM, cost allocations and requirement for family choice Other considerations: Is this feasible with pending time and motion study and cost reporting/reconciliation? Will this create confusion in paperwork and documentation? How does this impact CFCM compliance and supervisory structures? 14
Rates and Billing
Rate Rationale & Methodology NYS provided CMS with the Time and Motion study; found 75% of ICC time devoted to care coordination informed the proposed unbundled rates Services outside of the bundle comparable to current rates with trending for inflation Proposed rates are interim, with the understanding the State has agreed to a retrospective cost reconciliation process and time and motion study, as well as the expectation the 1915c Waiver will transition to Medicaid managed care & ICC would convert to Health Homes 16
Billing Rates (Current Services) SERVICE UNIT UPSTATE DOWNSTATE 1a. Intensive Care Coordinator Monthly $1,173.33 $1,232.01 2a. Respite Care, Individual 15 min $14.82 $15.61 2b. Respite Care, Group 15 min $8.15 $8.59 2c. Respite Care, Group of Three 15 min $5.92 $6.24 3a. Family Support Services, Individual 15 min $17.04 $17.50 3b. Family Support Services, Group of 2 15 min $9.38 $9.63 3b. Family Support Services, Group of 3 15 min $6.81 $7.00 3b. Family Support Services, Group of 4 15 min $5.11 $5.25 3b. Family Support Services, Group of 5-8 15 min $4.27 $4.38 4a. Intensive In Home, Brief, 30 min minimum 30 min $102.65 $110.86 4b. Intensive In Home, Full, 60 min minimum 60 min $124.04 $133.96 4c. Intensive In Home, Extended, 90 min minimum 90 min $166.81 $180.16 5a. Crisis Response, Brief, 30 min minimum 30 min $128.31 $138.58 5b. Crisis Response, Full, 60 min minimum 60 min $158.25 $170.92 5c. Crisis Response, Extended, 90 min minimum 90 min $187.34 $202.33 5d. Crisis Response, Triage - by telephone 15 min $23.17 $25.99 6a. Skill Building, Individual 15 min $17.04 $17.50 6b. Skill Building, Group of 2 15 min $9.38 $9.63 6c. Skill Building, Group of 3 15 min $6.81 $7.00 17
Billing Rates (New Services) SERVICE UNIT UPSTATE DOWNSTATE 7a. Youth Peer Advocate, Individual* 15 min $14.82 $15.61 7b. Youth Peer Advocate, Group of 2* 15 min $8.15 $8.59 7c. Youth Peer Advocate, Group of 3* 15 min $5.92 $6.24 8. Supported Employment, Individual * 15 min $17.04 $17.50 9a. Pre-Vocational Services, Individual* 15 min $17.04 $17.50 9b. Pre-Vocational Services, Group of 2* 15 min $9.37 $9.63 9c. Pre-Vocational Services, Group of 3* 15 min $6.80 $7.00 Transitional Case Management (TCM) 15 min $32.32 $34.02 18
Billing Codes Code Description 4650 ICC Full Month 4651 ICC Half Month 4653 Respite Individual, 15min 4655 Family Support Individual, 15mins 4656 Skill Building Individual, 15min 4657 Intensive In Home Brief, minimum 30min 4658 Intensive In Home Full, minimum 60min 4652 Intensive In-Home Extended, minimum 90min 4659 Crisis Response Brief, minimum 30min 4660 Crisis Response Full, minimum 60min 4654 Crisis Response Extended, minimum 90min 4372 Respite Group of 2, 15min 4373 Respite Group of 3, 15min 4374 Family Support Group of 2, 15min 4375 Family Support Group of 3, 15min 4376 Family Support Group of 4, 15min 4377 Family Support Group of 5-8, 15min 4378 Skill Building Group of 2, 15min 4379 Skill Building Group of 3, 15min New Services 4380 Youth Peer Advocate Individual 4381 Youth Peer Advocate Group of 2 4382 Youth Peer Advocate Group of 3 4666 Pre-Vocational Services Individual 4667 Pre-Vocational Services Group of 2 4668 Pre-Vocational Services Group of 3 4665 Supported Employment Services Individual 4398 Flexible recipient service dollars (state funded only as of 1/1/15) 1148 Crisis Response by Telephone, 15min 1149 Transitional Case Management, 15min 19
Limitations Case ratio for the HCBS Waiver under the 1915c for the ICC service is 1:9 (will move to 1:12 for children scoring high acuity when HCBS services move to Medicaid Managed Care and ICC to Health Homes) ICCs will maintain number of required contacts to assure quality of care, monitoring of child and family through programmatic shifts ICC Agencies must also stay within overall budget limits per year and slot/child enrolled in Waiver as outlined in the fiscal worksheets supplied by OMH and follow required procedures for approval of budgets that exceed annual limits 20
Limitations Children s HCBS Wavier Service Individualized Care Coordination Current OMH Waiver Service Limitations One billed case rate a month per participant Proposed OMH Waiver Service Limitations One billed case rate a month per participant Respite Maximum billing of 6 Limit of 6 hours a day hours a day Skill Building None Limit of up to 4 hours a day not to exceed 10 hours a week Family Peer None Limit of up to 4 hours a day not to exceed 10 hours a week. One billable Support service a day Intensive In Home N/A - Bundled Limit of up to 4 hours a day not to exceed 24 hours a month Crisis Response N/A Bundled Limit of 2 Face to Face units per day (pre-authorization for billing if more is needed). Limit of up to Two (2) -15 minute units for telephone contact and no more than two units daily Youth Peer Advocate Pre-Vocational Services Supported Employment N/A N/A N/A Limit of up to 4 hours a day not to exceed 10 hours a week. One billable service a day Limit of up to 4 hours a day not to exceed 8 hours a week. One billable service a day. Child must be 14 or older. Limit of up to 4 hours a day not to exceed 8 hours a week. One billable service a day. Child must be 14 or older. 21
Billing Rules for ICC CURRENT RULES: (*May be subject to change pending CMS approval): ICC Full Month Billing: 6 required face-to-face contacts per month at least 3 with child and other 3 can be family member or other service provider (collateral). Minimum of 15 minutes each. Must be enrolled for at least 21 consecutive days in the calendar month ICC Half Month Billing: at least 3 face to face contacts, 2 with child and 1 with collateral. Minimum of 15 mins each and enrolled at least 11 consecutive days in the calendar month. 22
Transitional Case Management Transitional Case Management (TCM) is designed to provide coordination and continuity of care by supporting youth and family/natural support system in transition from an inpatient or residential setting to a community setting. TCM provides case management prior to transitioning to Waiver from an inpatient or residential setting, and also to youth enrolled in Waiver that require temporary inpatient care. Previously referred to as ICC inpatient 23
Transitional Case Management As part of the shift and unbundling, providers to bill caseby-case transitional care management for youth in inpatient or residential settings TCM prior to enrollment in waiver can be claimed for a maximum of 30 days (between the signing of the Waiver Application and enrollment date) Taking over what would previously be billed as ICC inpatient Billed in 15 minutes increments in one claim AFTER discharged from setting and back in the community 24
Billing Rules: IIH and CRS Currently: IIH & CRS telephone and face to face: reimbursement for an average of 65 IIH and/or CRS contacts per slot included in the monthly case payment IIH and CRS face to face: Billed monthly per 15 minute contacts(contacts must be minimum of 30 minutes each to bill) CRS telephone calls: billable for up to 48 phone contacts annually per slot of a minimum of 15 min. each contact Moving Forward: IIH Face to face to the child or child and family Minimum of 30 mins for brief, 60 mins for full, 90 mins for extended Limit of up to 4 hours a day not to exceed 24 a month CRS Face to face or telephone contact 30 min, 60 min, or 90 min units for face to face 15 min unit for telephone CRS cap to bill twice per day up to 90 minute units 25
Billing Rules: Crisis Response Up to two 15 minute telephone contacts are allowed to be billed per day, if needed CR face-to-face can be provided in 30, 60 or 90 minute units for up to two a day (up to a 90 minute contact each) If an additional face-to-face contact is needed, the agency must receive pre-authorization prior to billing, once verifying documentation has been provided to the state 26
Discussion of Caseload Models: DOWNSTATE AND UPSTATE
Fiscal Implications
CMS Requirements Although CMS modified rates significantly, in order to get the interim rates and enhance fiscal integrity, CMS required a number of actions to consider renewal of the Waiver, including: Audits by the Office of the Medicaid Inspector General (OMIG) A Retrospective Cost Reconciliation to CFR Reports A Time and Motion Study of the ICC service 29
OMIG Audit OMH worked with the OMIG to develop audit protocols based on the HCBS Guidance Document Case records will be reviewed based on existing HCBS Waiver requirements Audits for the calendar year 2014-2015 will begin June 2017 Some agencies may have already been contacted and notified they will subject to audit 30
Clear Documentation Initial planned delivery of service and annual recertification must be authorized by LGU and documented in the child's service plan. Quality reviews at 90 days by ICC supervisor. The services provided must align with the definition and description of the service in the guidance document and support the achievement of the Waiver child s identified goals. A Progress Note must be written for every contact and all fields must be completed. Clear documentation of what service is provided, by whom, and for which goal must be noted. A qualified individual providing multiple services must delineate between services, goals, timeframes, and those served in documentation. 31
Time & Motion Study The objective of the survey is to account for all time spent by the care coordinators in delivering services, traveling, performing non- billable activities AND personal time during a specified timeframe. The State will employ an independent evaluator to conduct the above referenced time and motion study to be completed and reported in summary to CMS no later than December 31, 2017. The study will help to substantiate the rate request and demonstrate the time and effort spent by care coordinators per child enrolled in the HCBS Waiver 32
Cost Reconciliation CMS is requiring that OMH engage in a retrospective reimbursement reconciliation process using service provider cost of all services compared to the final allowable Medicaid reimbursement rate by service. FFP would be limited to the actual cost of the service(s) at the service provider level. If service providers received reimbursement in excess of their cost, the State would (1) reduce reimbursement to the service providers actual cost (2) any excess of actual cost could not be claimed for FFP and any excess would have to be refunded to CMS. 33
New Program Codes for CFR Reporting 2230 Children s HCBS Waiver Individualized Care Coordination (includes transitional case management (TCM) anticipate to be the same person) 2240 Children s HCBS Waiver Respite 2250 Children s HCBS Waiver Family Support 2260 Children s HCBS Waiver Crisis Response 2270 Children s HCBS Waiver Skill Building 2280 Children s HCBS Waiver Intensive In-Home 2350 Children s HCBS Waiver Supported Employment 2360 Children s HCBS Waiver Pre-Vocational Services 2370 Children s HCBS Waiver Youth Peer Advocate 34
Program Services
How Can Managers Prepare? II. Programmatic Concerns i. Orienting Children and Families to a new way ii. Operationalizing New Staff Roles iii. Opportunities for Staff Assignments 36
Messages for Families The Waiver program is intended to wrap services and supports around a child and family. Families must be aware that Waiver involves a team of providers working together to support their individualized needs Through collaboration and coordination, families have access expert staff that specialize in particular areas focused on helping to address their unique needs 37
Services Review Unbundled Services ICC, Crisis Response, and Intensive In-Home Existing Services How do the unbundled core services interact with and compliment the additional available services below Current Services: Family Peer Support, Respite, and Skill Building New Services: Prevocational, Supported Employment, Youth Peer Support (Transitional Case Management) 38
ICC Care Coordination ICC will be responsible for the overall coordination of the services for the child. Controls the flow of information This will include regular contact with the child/family as well as frequent collateral contacts Utilization of community resources Documentation The ICC role includes the services provided under Transitional Care Management 39
HCBS Waiver Transformation Category of Change Service PAST: Current 1915c Bundled (ICC/ IIH/ CRS) Rates ~$2300 downstate/ bundled Conflict of Interest Requirement N/A NOW: 1915c Application Renewal Unbundled Services ~$1200 downstate/ ICC Conflict Free Case Management FUTURE: SPA/ Health Home/ Managed Care Individual Services ~$800 downstate/ high acuity Conflict of Interest Case Ratio 1:6 1:9 1:12 (High Acuity) Care Coordination Service: bundled with other services Staff Qualifications Preferred Masters Coordination of all care Align with Health Home (Bachelors) Coordination of all care Bachelors Degree
Proposed New Protocols Required Monthly Contacts and Activities Submitting proposal to modify contacts and activities Reduce face-to-face requirements Increase other required contacts with collaterals and providers Required Documentation for Service Plans Considering removing requirement for 30-day review Enhance expectations for Initial Service Plan Utilize addendums for updating Service Plans and modifying needs and services 41
ICC Care Coordination Redefining the Role of the ICC: Considerations Expanding to include Transitional Aged Youth (TAY): Knowing community resources Increased attention to health care needs Increased facilitation role in accordance with Wraparound approach Warm hand-off : Introducing family to Waiver providers, community resources, discharge planning/ options 42
Intensive In-Home IIH works with family on the goals outlined in the Waiver Service Plan, with consideration to the existing Treatment Plan (implemented by clinical provider). The Intensive In-Home (IIH) worker provides services that support the child's social and emotional development and learning. Articulating the needs, strengths and priorities of the family back to the ICC 43
Intensive In-Home (cont.) Redefining the Role of IIH: Considerations Conceptualizing the role Relationship IIH provider is providing clinical interventions (e.g., coping strategies, behavior de-escalation, etc.) IIH has a unique role in providing interventions that address the clinical aspects of the child and family s needs which requires the highest qualified and trained provider (as well as Crisis Response) in the Waiver program. Time Management 44
Crisis Response Crisis Response Services (CR) reinforce the agreed upon safety plan that the child and family have developed and attempts to stabilize occurrences of child/family crises when they arise. These services may include: assessment consultation linkage immediate intervention wherever necessary, for example, in schools, at home and work. This service is available 24 hours a day, seven days a week. 45
Crisis Response (cont.) Considerations: Service provider s role when a crisis develops while with the family/ youth: Skilled in behavioral deescalation, updated on Safety Plan When to call Crisis Response or emergency services Fluid communication with ICC: Follow-up Parameter of service provision: billing considerations, best practice 46
Process & Case Examples Family Other Providers ICC Community Resources IIH CRS Other HCBS Services 47
Family Support Family Support is designed to enhance the health and growth of children and adults in the family unit to ultimately develop safe, stable, and supportive families who are connected to their communities. Family Support Services: provide resources, including, but not limited to education, training, advocacy and supports assist the family by introducing and connecting them to activities in the community (e.g., educational, cultural, recreational) which would foster family cohesion may be provided to Waiver parents/guardians and family members who have frequent and regular caretaking responsibilities for the Waiver child 48
Skill Building Skill Building Services (SBS) focus on helping the child be successful in the home, community and school by acquiring both social and environmental skills associated with his/her current developmental stage. Utilizes an individualized, strength based approach to assist the child recognize functional assets/strengths and those that need developing. Skill Building may also assist youth to develop skills for independent living and by facilitating access to, monitoring and supporting vocational training. 49
Respite Services Respite Services (RS) provide a needed break for the family and the child to ease the stress at home and promote overall wellness for the child and his/her family. Activities include: providing supervision and recreational activities that match the child's developmental stage and/or community outings with child Respite care may be provided on a planned or emergency basis, day or night, in the child's home or in the community by trained respite workers with one Waiver child or a group of Waiver children 50
How Can Expansion Help? III. Expanding to New Populations/Services i. Serving TAY in Expanded Enrollment Age ii. Providing New Waiver Services a. Youth Peer Advocates b. Pre-Vocational Services c. Supported Employment 51
New Services NYS working through amendment and waiver process with CMS with the intent to: Expand the allowable age of enrollment from up to the age of 18 to up to 21 years old Add three new services: Youth Peer Advocate, Pre- Vocational Services, and Supported Employment **No designation process for current waiver providers, they can elect to provide if they have qualified staff and follow subcontractor approval process 52
New Services Youth Peer Advocate Offer positive youth development-centered services for a waiver participant who is at a developmentally appropriate age with a resiliency/recovery focus. Promoting skills for coping and symptom management and the use of available resources. Pre-vocational Individually designed to prepare a youth age 14 or older with serious emotional disturbance to engage in paid work, volunteer work or career exploration. Not job-specific Geared toward facilitating success in any work environment Supported Employment Provide assistance to waiver participants age 14 or older with severe disabilities as they perform in a work setting. 53
Looking Ahead
How Will This Prepare Me? IV.Readying Staff for Future Services i. Future of Care Coordination ii. New SPA Services iii. Opportunities of New HCBS services Array 55
Future of HCBS Waiver Moving to Health Homes Integrated Care Focus on Whole Health Collaboration/Coordination with Array of Healthcare Providers Moving to Medicaid Managed Care Assuring Quality of Care Demonstrating Outcomes Value Based Payments 56
Updated Children s System Transformation Timeline Updated Children s Behavioral Health and Health Medicaid Redesign Implementation dates as submitted to CMS as part of amendment to the 1115 New York Medicaid Redesign Waiver July 1, 2018 Transition 1915(c) Children s Waivers to Health Home Align Children s Home and Community Based Services for Level of Care Population Children s Behavioral Health Benefits Transition to Managed Care January 1, 2019 Foster Care Population Transitions to Managed Care Expansion of Children s HCBS for Community Eligible and Family of One Level of Need Population 57
What the transition timeline means for Waiver Services? Moving towards new structures and processes that align with redesign and managed care Creating more seamless programmatic and fiscal transitions to new services Preparing for changing ways of doing business that focus more on individualized service arrays and less on programs Develop capacity and specializations in areas that will continue in new services and models 58
Moving to Health Homes Aligned staffing qualifications of ICC to be commensurate with Health Home high acuity Create opportunities for specialization in care coordination efforts and approaches to whole health Orient staff to the wide array of available services from multiple child-serving systems Establish relationships with common health care practices and providers to better integrate care Move towards value based approaches focused on outcomes correlated with research 59
Staff Qualifications ICC Staff qualifications now align with required qualifications for staff serving Health Homes High Acuity youth: Bachelor s degree or a NYS Teacher's Certificate and two years experience* providing direct services for children in the children s service system with a preference for the mental health field/working with children with SED -- OR -- a Master s degree and one year experience* providing direct services to children, or providing linkage to services, for children, in the children s service system with a preference for the mental health field/working with children with SED. Also applies to Transitional Case Management *Qualifying experience may be pre-or post-degree. Candidates may qualify by meeting the qualifications for the NYS Intensive Case Manager position 60
Readying Staff for Future There will be many opportunities for staff at varying levels in the Waiver program to provide an array of services under the new State Plan services and expanded array of HCBS services. Waiver Service Redesign Service Qualifications ICC HHCM Same IIHS SPA - CPST Bachelors/Masters Skill Building PSR/ Habilitative SB High School Diploma FPSS/YPA SPA - FPSS/YPSAT Training/Credential Crisis Response SPA - Crisis Intervention Licensed Practitioner Respite HCBS - Respite High School Diploma B2H F/CSS HCBS - C/FSS ------ B2H - SNCAS HCBS- CSATS ------
Next Steps
Technical Assistance Slides will be distributed electronically following the series A Q&A resource will be developed and distributed A web-based office hour will be offered in late June/July to talk through ongoing implementation and additional questions Please send questions to: ctac.info@nyu.edu 63
Ongoing OMH Updates Regular Monthly Webinars Impromptu Webinars, as needed Issuance of New Guidance Document with CMS Approval of Waiver renewal Policy Change Notices Notification emails 64
Thank you! Discussion/Q&A HCBS Waiver Unit Email & Main Division Phone Number: dcfs@omh.ny.gov & (518) 474-8394 Contact the Community Technical Assistance Center at ctac.info@nyu.edu 65