Redesign Medicaid in New York State Behavioral Health Medicaid Managed Care Kick-Off Forums
Presented by: Gary Weiskopf, Associate Commissioner for Managed Care, NYS Office of Mental Health Donna Bradbury, Associate Commissioner for Integrated Community Services for Children and Families, NYS Office of Mental Health Linda Kelly, Project Director, Behavioral Health Transition, NYS Department of Health Pat Lincourt, MSW, Director, Clinical Services Unit, OASAS Ilyana Meltzer, MPP, Addictions Planning Analyst, Division of Practice Innovation and Care Management, OASAS 2
Agenda Welcome NYS General Managed Care Overview of key features NYS Behavioral Health (BH) Transition Medicaid Managed Care Introduction to Managed Care Technical Assistance Center (MCTAC) Phased Approach to Technical Assistance Discussion of Critical Factors for Managed Care Readiness Available Resources and Training Opportunities Plan/Provider Networking Opportunities 3
Redesign Medicaid in New York State Medicaid Managed Care: An Overview September 2014
Introduction Where are we today? What does the Medicaid Managed Care Program look like right now? Who must enroll in a Medicaid Managed Care Plan? What do providers need to know about working with Medicaid Managed Care Plans? Where are we going? 5
What is Managed Care? Managed Care is a general term used to describe any health insurance plan or system that coordinates care through a primary care practitioner or is otherwise structured to control quality, cost and utilization, focusing on preventive care. Principles of managed care can be found in many health insurance products from indemnity plans, PPOs, EPOs, to ERISA and Self Insured plans. Authorization Capitation Referral Preferred networks 6
Medicaid Managed Care A NYS-sponsored health insurance program for adults and children who have little or no income or who receive Supplemental Security Income (SSI) Authorized under Section 364-j of Social Services Law NYS contracts with Managed Care Organizations who then pay the participating provider directly for services NYS pays the plans a capitated rate (per member/per month) Benefits consist of plan covered services and Medicaid FFS carveout services Most carve-out services will be covered by MMC by 2015 4,038,921 Medicaid recipients enrolled statewide as of July 2014 7 7
Medicaid Managed Care Plans NYS Mainstream Medicaid Managed Care Plans (MMCP) Are HMOs, PHSPs, or HIV SNPs Certified under Article 44 of the Public Health Law By the NYS Department of Health in conjunction with the NYS Department of Financial Services Qualified by NYS Department of Health to provide Medicaid services Meet federal regulations at 42 CFR 438 These plans are responsible for assuring enrollees have access to a comprehensive range of preventative, primary, specialty, ancillary and inpatient services through their provider network 8
Basics of Coverage MMC enrollees are entitled to all Medicaid covered benefits FFS coverage is the minimum level of service that plans must provide Plans may establish their own: Prior approval policies Reimbursement levels/methodologies Medical necessity (utilization review) criteria 9
What Is Covered Under Medicaid Managed Care? Inpatient Hospital Services Emergency Services Physician/Nurse Practitioner/Midwifery Services Preventive Health Services Laboratory Services Radiology Services Prescription/Non Prescription Drugs and Medical Supplies Home Health Services 10
What Is Covered Under Medicaid Managed Care? Mental Health/Substance Use Disorder Dental Orthodontia Rehabilitation Services Durable Medical Equipment (DME) Vision Care Personal Care Services Consumer Directed Personal Assistance Hospice Services Family Planning (Fidelis does not cover; services are available through FFS Medicaid) 11
Current Mental Health (MH) & Substance Use Disorder (SUD) Services Inpatient MH Services Covered; including voluntary and involuntary admission MMC SSI related Enrollees access through Medicaid FFS Outpatient MH Services Covered; MMCP must make available in an accessible manner all services required by OMH regulations found at 14 NYCRR 599 MMC SSI related Enrollees access through Medicaid FFS Inpatient SUD Services Covered pursuant to OASAS regulations found at 14 NYCRR 818 Outpatient SUD Services MMC Enrollees access outpatient chemical dependency services and Opioid clinics through Medicaid FFS 12
Behavioral Health Behavioral Health Managed Care Vision: Fully integrated treatment where behavioral and physical health are valued equally and patients recovery goals are supported through a comprehensive and accessible service system Integration of all Medicaid Behavioral Health (BH) and Physical Health (PH) benefits under managed care 13
Enrollment into a Plan Enrollment into a Medicaid Managed Care Plan is mandatory unless the individual is exempt or excluded 14
MMC Application Avenues New York State of Health, The Official Health Plan Marketplace or by phone at (855) 355-5777 Medicaid Managed Care Plan Navigators and Certified Application Specialists Medicaid Helpline (800)541-2831 Local District Social Services Offices 15
Enrollee Education: Medicaid Managed Care Education Process Primarily the responsibility of the LDSS; NYS enrollment broker, New York Medicaid CHOICE; or Application Counselor May be in person, over the phone, via internet or by mailings Education Includes: Choice of plans and services offered Provider information How to change plans and/or providers Consumer rights 16
Exemptions Most Medicaid eligible individuals are required to enroll in a MMCP unless exempt or excluded An exemption means that a consumer is not required to join a MMCP unless he or she so chooses If a consumer is already enrolled in a MMCP and applies for and receives an exemption, he or she will be disenrolled from the MMCP Exempt individuals can choose to enroll in a plan or remain in FFS Medicaid: Person with chronic medical conditions with a non-participating physician limited to a single 6 month exemption Residents of long term substance use disorder treatment programs Developmentally Disabled and other waivered individuals Native Americans 17
How to Obtain an Exemption Many exempt and excluded individuals are system identifiable, and the consumer does not need to apply for an exemption (Waiver Programs and Developmentally Disabled individuals) There are a some exemptions when application is necessary: Six month chronic medical Long term residential Residents of Intermediate Care Facilities Native Americans must verify their status with official documentation 18 18
Who Is Excluded From MMC? Medicaid/Medicare dually eligible individuals Persons with comprehensive Third Party Health Insurance (TPHI) Individuals who will be eligible for Medicaid only after spending some of their own money for medical needs (spend-down cases) Individuals residing in nursing homes or hospice programs at the time Medicaid application is submitted Individuals eligible for TB services only 19 19
When Does Coverage Begin? Medicaid Managed Care: Medicaid eligibility is established first MMC enrollment is processed prospectively Eligibility begins in the month of application, and may include the three prior months in some cases Medicaid eligible individuals are covered by FFS Medicaid until the plan enrollment is effectuated 20 20
When Does Coverage Begin? Example: Medicaid application submitted 5/12/2014 If eligible, the consumer receives FFS Medicaid coverage beginning 5/1/2014 Consumer selects a plan on 6/12/2014 Effective date of enrollment in a MMC health plan is 7/1/2014 21 21
Working with Medicaid Managed Care Plans Consumer Rights Provider Rights Authorizations and Appeals 22 22
Right to information about plans Benefit description Referral and authorization requirements Provider network Access to needed care Right to out of network care Prudent layperson emergency care Transitional care Access to specialty care & specialty care centers NYS Medicaid Managed Care Consumer Rights Right to complain, grieve and appeal Notification of denials of treatment and grievance outcomes Clinical rationale for the denial Appeal of denials & timeframes for responding If appeal timeframes not met, the denial is reversed External appeal For MMC Expanded transitional care Right to appeal any plan Action Right to Fair Hearing and Aid Continuing Reasonable assistance filing complaints and appeals 23
NYS Provider Rights Statute and Current MMC requirements: Patient/Provider relationship Contract Requirements Network Requirements Payment Rules Authorizations and Appeals 24
Patient/Provider Relationship Provider may discuss all treatment options with member, even if service not be covered by plan. Provider may assist the enrollee with a grievance, appeal or external appeal. No penalty or retaliation if provider files complaint with government entity. Provider contract may not be terminated solely because provider advocated for enrollee; filed complaint; appealed plan decision; or asked for hearing. 25
Provider Contracting Provider Contract Guidelines plan submits contracts to NYSDOH for approval http://www.health.ny.gov/health_care/managed_care/hmoipa/hmo_ipa.htm Applies to IPA arrangements NYSDOH reviews risk sharing arrangements; HMO must retain some risk. Contract must provide the payment methodology; manner and timing of adjustments; and process for disputing and correcting errors. Hearing process if health plan seeks to terminate contract (except if immediate patient harm). 90 day notice and opt out for plan initiated adverse change in contract reimbursement (unless otherwise agreed to in contract). 26
Network Requirements Upon request, plans must provide: Written application procedures the criteria & minimum qualifications provider must meet to be credentialed Credentialing qualifications must be developed with input from qualified health professionals Completed network application must be reviewed in 90 days applicant notified whether s/he is credentialed or whether additional time is needed because there is a lack of necessary documentation from a third party Performance Reviews Plan must inform providers of information the plan has to evaluate the performance of the provider Plan must consult providers in the development of profiling methodologies and analysis Profiling data must be measured against standard criteria and that of a similar group of providers with a comparable patient population Providers must be given opportunity to discuss unique nature of their patient population 27
Payment Rules Prompt Pay Law 30 day processing of clean electronic claims Written notice of reason for denied claims Insurer pays interest for late payments At least 90 days to file claims (MMC nonpars have 15 months) Untimely filing dispute resolution process Coding dispute resolution process (art 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 28
MMC Service Authorizations No authorization required for ER Plan authorization determinations as per Appendix F of the Model Contract Notification requirements Includes both benefit determinations and medical necessity reviews Clinical decisions made by health professionals Based on written clinical criteria Once authorized, authorization may not be changed without receipt of new information, fraud or loss of coverage 29
MMC Service Authorizations New, review and notice in Expedited, 3 bd from request Standard, 3 bd from all info and no more than 14 days from request Concurrent, review and notice in Expedited, 1 bd from all info and no more than 3 business days from request Standard, 1 bd from all info and no more than 14 days from request Home health care following inpatient admission on Friday or day before holiday, 72 hours after all info, no more than 3 bd of request 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 Verbal and written notice made to enrollee and provider 30
Disagreements with Care Plan/ Adverse Determinations 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: Disagreements with Care Plan/ Adverse Determinations 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
Plan Action Appeals 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
External Appeal 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 34 34
Department of Health Complaints Enrollees and providers may file a complaint regarding managed care plans to DOH 1-800-206-8125 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
Provider Responsibilities 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
Resources 1. Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan Model Contract a) Section 10: Benefit Package Requirements b) Appendix F: Action and Grievance System Requirements c) Appendix K: Prepaid Benefit Package Definitions of Covered and Non-Covered Services 2. New York State Department of Health http://www.health.ny.gov/ 3. New York State Department of Financial Services http://www.dfs.ny.gov/ a) Provider rights: http://www.dfs.ny.gov/insurance/hprovrght.htm b) Prompt Pay Law: http://www.dfs.ny.gov/insurance/provlhow.htm 4. The Centers for Medicare and Medicaid Services http://cms.hhs.gov/ 5. Behavioral Health Transition http://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health_transition.htm 6. Medicaid Redesign Team http://www.health.ny.gov/health_care/medicaid/redesign/?utm_source=doh&utm_medium= hp-button&utm_campaign=mrt 37
Redesign Medicaid in New York State Implementing Medicaid Behavioral Health Reform
Transitioning Behavioral Health (BH) Services into Managed Care Important Features to Successfully Integrate BH Services into Managed Care
Medicaid Redesign Team (MRT): Objectives Redesigning New York's Medicaid Program home page http://www.health.ny.gov/health_care/medicaid/redesign/ Fundamental restructuring of the Medicaid program to achieve: Measurable improvement in health outcomes Sustainable cost control More efficient administrative structure Support better integration of care 40
Principles of BH Benefit Design and Services Management Person-Centered Care management Integration of physical and behavioral health services Recovery oriented services Patient/Consumer Choice Ensure adequate and comprehensive networks Tie payment to outcomes Track physical and behavioral health spending separately Reinvest savings to improve services for BH populations Address the unique needs of children, families & older adults Behavioral Health Transition to Managed Care Home Page http://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health_transition.htm 41
Findings from BHO Phase 1 42
100% BHO Phase I post-discharge outcomes for Adult Mental Health discharges, CY 2012 90% 80% 70% NYC Rest of state 60% 50% 40% 30% 20% 10% 0% 30-day readmission rate Outpatient MH or SUD treatment within 7 days of discharge Two or more MH outpatient visits within 30 days of discharge Medicaid claims data
BHO Phase I post-discharge outcomes for SUD discharges, CY 2012 100% 90% 80% 70% 60% NYC Rest of state 50% 40% 30% 20% 10% 0% 45-day readmission rate Lower level of SUD service or MH outpatient care within 14 days of discharge Three or more SUD lower level services within 30 days of discharge Medicaid claims data
Integrated Care: In BHO Phase I, how often did behavioral health inpatient providers identify general medical conditions requiring follow-up, and did they arrange aftercare appointments? No physical health condition identified: 64% Physical health condition identified: 36% No physical health appointment made: 82% Physical health appointment made: 18% Based upon 56,167 statewide behavioral health community discharges (all service types) January 2012 June 2013 Data submitted by BHO
In September 2014, the OMH BHO Portal was updated to include hospital provider specific data. Click Archived Reports tab at BHO Portal: https://my.omh.ny.gov/webcenter/spaces/bho 46
Behavioral Health Managed Care Program Design 47
Behavioral Health Services for Adults will be Managed by: Qualified health Plans meeting rigorous standards (several in partnership with a BHO) All Plans MUST qualify to manage currently carved out behavioral health services and populations Plans can meet State standards internally or contract with a BHO to meet State standards Health and Recovery Plans (HARPs) for individuals with significant behavioral health needs Plans may choose to apply to be a HARP with expanded benefits Expanded benefit includes Home and Community Based Services (HCBS) HARP members are eligible for enhanced Health Home Care Coordination 48
Qualified Managed Care Plan vs. Health and Recovery Plan (HARP) Qualified Managed Care Plan HARP Medicaid eligible Benefit includes Medicaid state plan covered services Organized as benefit within MCO Specialized integrated product line for people with significant behavioral health needs Eligible based on utilization or functional impairment Enhanced benefit package - All current PLUS access to HCBS Management coordinated with physical health benefit management Performance metrics specific to BH BH medical loss ratio Specialized medical and social necessity/ utilization review for expanded recovery-oriented benefits Benefit management built around higher need HARP patients All HARP members eligible to be enrolled in HH Performance metrics specific to higher need population and HCBS Integrated medical loss ratio 49
Adult Project Status Final RFQ for adults was distributed (with draft NYC HARP rates) on March 21, 2014 OMH: http://www.omh.ny.gov/omhweb/bho/phase2.html DOH: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health_transition.htm RFQ Applications were received on June 6, 2014 NYS is in the process of finalizing Plan designation for NYC Start date Adults NYC-April 1, 2015 Adults Rest of State - approximately six months later Kids- January 1, 2016 50
Behavioral Health Benefit Package Behavioral Health State Plan Services Adults Inpatient - SUD and MH Clinic SUD and MH Personalized Recovery Oriented Services (PROS) Intensive Psychiatric Rehabilitation Treatment (IPRT) Assertive Community Treatment (ACT) Continuing Day Treatment (CDT) Partial Hospitalization Comprehensive Psychiatric Emergency Program (CPEP) Opioid treatment Outpatient chemical dependence rehabilitation Rehabilitation supports for Community Residences (Not in the benefit package in year 1) 51
Menu of Home and Community Based Services in HARPs Rehabilitation Support Services Psychosocial Rehabilitation Family Support and Training Community Psychiatric Support Non- Medical Transportation and Treatment (CPST) Individual Employment Support Services Crisis Intervention Prevocational Short-Term Crisis Respite Intensive Crisis Intervention Transitional Employment Support Intensive Supported Employment Mobile Crisis Intervention On-going Supported Employment Habilitation Educational Support Services Empowerment Services and Peer Supports Self Directed Services 52
Behavioral Health Transition Features Two Year Transition Period Legislative and Contractual: Networking, contracting, and reimbursement requirements to support a stabilized two year transition period
Ensuring Adequate BH Networks: Network / Contracting Requirements Important to BH transition BH Network requirements include: Contracts with OMH or OASAS licensed or certified providers serving 5 or more 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 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 HARP must have an adequate network of Home and Community Based Services Health Homes 54
Promoting Financial Stability Through Payment and Claiming Requirements PAYMENTS CLAIMING Mainstream and HARP pay FFS government rates to OMH or OASAS licensed or certified providers for ambulatory services for 24 months HARP capitation rate does not include HCBS package in first year. NYS will establish initial HCBS payment rates. BH and HARP MLR Mainstream Plans will have a BH MLR HARP will have an integrated MLR 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. HARP MLR - percentage in NYC is 89% BH MLR- under development Plans must meet timely payment requirements 55
Supporting Access to Treatment and Recovery Support Services Ensuring that mainstream plans are focused and prepared to effectively manage BH services Working with plans to make Home and Community Based Services available to mainstream members Mandating the use of the OASAS LOCATDR 3 Clinical level of care tool that assesses the intensity and need of services for an individual with a Substance Use Disorder Supporting off site services in the OASAS system Seeking Federal State Plan Amendment (SPA) approval to allow off-site services by moving from a Federal Clinic SPA authority to Federal Rehabilitation SPA authority Outpatient treatment providers will still be authorized to provide OASAS services in their clinics but will also be able to provide these same services outside the four walls of the clinic 56
Network Training: Plans are Required to Train Behavioral Health Providers Plans will develop and implement a comprehensive BH provider training and support program that includes: Billing, coding and documentation assistance Data interface UM requirements Evidence-based practices HARPs train providers on HCBS requirements Training coordinated through Regional Planning Consortiums (RPCs) when possible RPCs are comprised of each LGU in a region, representatives of mental health and substance use disorder service providers, child welfare system, peers, families, health home leads, and Medicaid MCOs RPCs work closely with State agencies to guide behavioral health policy in the region, problem solve regional service delivery challenges, and recommend provider training topics RPCs to be created 57
Children s Medicaid Managed Care Design Update 58
Children s Proposed Benefits New State Plan Services New Home & Community Based Services Mobile Crisis Intervention Community Psychiatric Supports and Treatment (CPST) Other Licensed Practitioner Family Peer Support Services Care Coordination Skill Building Family/Caregiver Support Services Planned Respite Crisis Respite Day Habilitation Prevocational Services Palliative Care Supported Employment Services Community Advocacy and Support Youth Peer Advocacy and Training Non-Medical Transportation Adaptive and Assistive Equipment Psychosocial Rehabilitative Services Accessibility Modifications 59
Preparing the field: NYS State Partnership with Managed Care Technical Assistance Center (MCTAC) NYS has partnered with MCTAC as a training, consultation, and educational resource center that offers resources to ALL mental health and substance use disorder providers in New York State The goal of MCTAC is to 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 60
New York State Behavioral Health Medicaid Managed Care Kickoff Andrew Cleek, PsyD, McSilver Institute Charles Neighbors, PhD, MBA, CASA Columbia Meaghan Baier, MSW, Institute for Community Living Dan Ferris, MPA, McSilver Institute MCTAC.info@nyu.edu http://www.mctac.org 61
Kickoff Agenda Medicaid Managed Care Technical Assistance Center (MCTAC) Introduction Phase 1: Critical Factors & Readiness Assessment MCTAC Training Series Phase 2: Long Term Success Change Management & the Role of Leadership Discussion & Next Steps 62
Managed Care TAC (MCTAC) Overview What is MCTAC? 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. 63
MCTAC Overview MCTAC (cont.) MCTAC is partnering with OASAS and OMH to provide: Foundational information to prepare providers for Managed Care Support and capacity building for providers tools group consultation informational training assessment measures Information on the critical domain areas necessary for Managed Care readiness Aggregate feedback to providers and state authorities 64
Managed Care Technical Assistance Center 65
Previous Collaboration with Clinics Prior to the launch of MCTAC, a total of 340 or 69% of all adult and children s clinics in New York State (n=496) have taken advantage of at least one CTAC offering. The Children s Technical Assistance Center is in its fourth year of funding and has achieved a penetration rate of 78% (n=273). In the last twenty-one months, the Adult Technical Assistance Center has had a penetration rate of 67% (n= 286). More than 2,606 unique individuals and more than 7,389 participants have attended at least one of the 216 events offered by CTAC. 66
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About CASAColumbia CASAColumbia is: a science-based, multidisciplinary organization focused on transforming society s understanding of and responses to substance use and the disease of addiction the foremost organization translating and disseminating research findings in order to: link science to policy to practice bridge gaps that block progress by removing stigma and improving outcome 68
CASAColumbia Well-established national reputation in 3 major areas related to substance use and addiction: 1) translation of scientific findings and dissemination of information to the general public, policy makers, and providers (healthcare, education, social service) 2) policy reports and health services research (national surveys, regional program evaluation) focused on the financial and human costs of substance use and addiction on various sectors of American society 3) family-based adolescent substance use prevention and treatment research 69
CASAColumbia Well-documented track record of increasing the impact of scientific findings by getting them into the hands of: medical and public health experts state and local health commissioners national public policy makers Select examples of pioneering reports widely distributed and cited over the past 20 years include: Cost of Substance Abuse to America s Health Care System: Medicare and Medicaid Addiction Medicine: Closing the Gap Between Science and Practice Adolescent Substance Use: America s #1 Public Health Problem Shoveling Up: The Impact of Substance Use on Federal, State, and Local Budgets 70
CASAColumbia Treatment System Reform Initiatives Implement practical, evidence-based interventions for risky substance use and addiction Our work is founded on the principles of: a) evidence-based practice b) use of process improvement strategies to adapt implementation to local needs, and c) data-based performance monitoring to guide implementation as well as gauge success. Collaborating with OASAS to develop tools for negotiating level of addictions care decisions: LOCADTR Collaborating with DOH, OASAS, AIDS Institute and OMH on evaluating Health Home and other Medicaid reform efforts Collaborating with OASAS and large healthcare system to implement substance use screening and interventions 71
MCTAC Partners 72
Center for Practice Innovations www.practiceinnovations.org CPI helps agencies to implement evidence-based practices Training for practitioners Implementation support for managers Practices include: Care coordination; Employment; Motivational Interviewing; Engagement Strategies; Co-occurring substance use disorder and mental illness problems; Assertive community treatment; Wellness self-management; Suicide prevention CPI s reach is wide: Over 1300 programs Over 182,000 online modules completed by 16,000 learners CPI will work closely with managed care companies to develop focused training in EBPs this training will begin shortly Managed care companies are already asking for information about agency/program participation in CPI s training activities 73
Drowning in acronyms FIDA 74
MCTAC SCOPE Licensing Office Number of Agencies OASAS 444 OMH 545 OASAS and OMH 107 UNIQUE ORGANIZATIONS 887 75
Managed Care TAC (MCTAC) Goals Provide agencies with critical information necessary to prepare for the transition to Managed Care as early as April 1, 2015. Provide content training and support in preparing agencies for the implementation of Managed Care. Obtain a thorough assessment of agencies existing readiness to transition to Managed Care. 76
MCTAC will offer: Foundational information to prepare for Managed Care Support and capacity building for providers o tools o consultation o informational forums o assessment tools Critical information along each of the domain areas necessary for Managed Care readiness Feedback to providers and state authorities on readiness for Managed Care. MC TAC will serve as a clearing house for other Managed Care technical assistance efforts 77
What will MCTAC do? Hold Kick Off events around NY State Distribute and collect a Managed Care Readiness Assessment Offer training series to providers based on two levels of need: Informational Training Series: Managed Care Foundational Concepts Training Series Intensive Training Series: Intensive Implementation and Planning Action Learning Community 78
Level 1: Managed Care Foundational Concepts Training Series Training topics will include: Understanding MCO Priorities MCO Contracting Billing Communication /Reporting IT System Requirements Credentialing Process Level of Care (LOC) Criteria / Utilization Management Practices Member Services/Grievance Procedures Medical Management Quality Management/Quality Studies/Incentive Opportunities Cash Flow Management Revenue Cycle Management Access Requirements Demonstrating Impact/Value (Data Management & Evaluation Capacity) 79
A Conceptual Framework Triple Aim of Improving Health Systems Improving the patient experience of care (including quality and satisfaction); Improving the health of populations; and Reducing the per capita cost of health care. 80
INFORMATIONAL TRAINING TOPICS 81
Understanding Managed Care Shifting from a volume based to an outcome based organization Clinical and Business Implications Transitioning from Utilization Review to Utilization Management Understanding HARP and HCBS Role and functions of physicians in a managed care environment 82
Understanding Your Population What insurance plans are your clients currently enrolled in for physical health, or behavioral health as applicable Developing an agency wide profile of your population served and needs including HARP and HCBS Understanding your internal service patterns Have all your HARP eligible clients been enrolled? 83
Contracting Do you have current contracts with MCO s? Have you met with the MCO s in your region? What is your plan for developing contracts with all MCO s in your region? How do insurance plans in your region differ across factors such as authorization, billing, and utilization management? Reporting Requirements for each MCO Access Requirements 84
Contracting (continued) Content unit beginning in mid-november Online and in-person events scheduled Initial forum will cover negotiating basics and smart Managed Care contracting Online sessions will include government and provider perspectives More information in your email and at www.mctac.org 85
Business Operations Billing Cash Flow Management Revenue Cycle Management IT 86
Utilization Management Medical necessity Length of stay Clinical outcomes Level of Care Medical Management OASAS LOCADTR 87
Initial MCTAC Offerings Contracting with Managed Care Basic MCO Contracting Facts MCO 101 Panel of MCO execs In person sessions throughout the state or Web Billing 88
MCTAC Tools Sample MCO 101 Slides for Presentations to: Board Members Front Line Staff Guide to differences between MCO s across Key Domains MCO 101 Quick Facts Sheet 89
Foundational Concepts Training Series Trainings will begin in the fall and continue through Managed Care launch»in-person and webinar based Follow-up consultation» Following each training topic, MCTAC will provide at least one group consultation session to address questions and implementation challenges. 90
Intensive Implementation and Planning Action Learning Community For select Informational Training topics, an intensive Learning Community will be offered in partnership with OMH/OASAS based on provider feedback and Readiness Assessment results. Some preliminary Learning Community topics include: Finance/Business Cash-flow Revenue Cycle Management Billing Utilization Management 91
Intensive Implementation and Planning Action Learning Community Learning Communities will address topics that are the priority needs of providers Participants will have access to content from the Informational Training Series and can self-select which parts of the Learning Community to participate in based upon their interests/needs. The Intensive Training Series will begin through Managed Care launch and as needed ongoing 92
Intensive Implementation and Planning Action Learning Community Participants will be assigned to cohorts based on their areas of interest/need and level of readiness Learning Community Cohorts will participate in at least four implementation and problem solving sessions Participants will develop an implementation plan collect and report critical data elements 93
MCTAC Training Series Both the Informational and Intensive trainings will be offered again in 2015 The training series will be repeated and provided to children s providers later on. Both the Fall 2014 and Spring 2015 offerings are available to all Upstate and Downstate providers 94
MANAGED CARE READINESS ASSESSMENT 95
Managed Care Readiness Assessment Content Areas Understanding MCO Priorities MCO Contracting Communication /Reporting IT System Requirements Credentialing Process Level of Care (LOC) Criteria / Utilization Management Practices Member Services/Grievance Procedures Medical Management Quality Management/Quality Studies/Incentive Opportunities Finance and Billing Access Requirements Demonstrating Impact/Value (Data Management & Evaluation Capacity) 96
Readiness Assessment Readiness Assessment available in your folder Was distributed online starting 9/10/14 Were due back to MCTAC on October 10, and are still being accepted on a rolling basis Agencies are strongly encouraged to complete the assessment as part of a management team meeting Individual agency information will be kept confidential 97
Managed Care Readiness Assessment Data Collection and Analysis Data collection: online through Qualtrics Analyze collected data: Examine readiness and preparedness for the transition to managed care and identify areas where additional support is needed Report: MCTAC will present aggregated data to relevant stakeholders 98
Timeline 99
MCTAC Timeline Kick Off Events Readiness Assessment September & October 2014 September & October 2014 Informational Training Series Intensive Training Series October October ongoing ongoing 100
Looking ahead to 2015-2016 With the foundation and critical elements in place for operating under Managed Care, MCTAC will offer trainings on a range of topics that may include: Outcomes management Emphasizing partnerships New business structures Development of new clinical & program models And more! 101
Since 2011, CTAC has assisted with: Change Management Continuous Quality Improvement Workforce Development 102
Change Management Leadership: Guiding an organization through rapid and uncharted waters
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So basically we need to : 105
Understanding the Impact of Change on the Workforce 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 shock change. Woodward, H. and Woodward, M.B. (1994). Navigating Through Change. NY: McGraw Hill. 106
What Participants Can Do to Make the Most of MCTAC Supports Designate a project team including: Executive leadership, Finance & Clinic leadership, and Evaluation staff when available Complete the readiness assessment and participate actively in MCTAC activities Commit to investing the time and effort needed to assess, diagnosis, improve, and monitor your organization s operations, business practices, and financial performance 107
Discussion We want to hear from you! What topics, information, and tools would be most helpful to assist with the transition to managed care? What other technical assistance could we provide in the fall and beyond? 108
The New York State Office of Mental Health and the Community Technical Assistance Center of New York are Announcing a New Webinar Series: Reimagining Children s Mental Health Services Part I: What s on the Horizon? November 7, 2014 1:30pm 3:00pm Presenter: Donna Bradbury, MA, LMHC Associate Commissioner, Division of Integrated Community Services for Children and Families New York State Office of Mental Health Description: Learn about the current state of children s mental health services and important changes all child-serving organizations need to know. Learn how CTAC will provide supports to the full child-serving system in this transition. Register at CTACNY.com 109
Thank you very much for your participation! Contact us: MCTAC.info@nyu.edu Visit MCTAC s website for more information and access to past webinars and trainings: http://www.ctacny.com/managedcare 110