Maryland Medicaid s Partnership in Improving Behavioral Health Services Susan Tucker Executive Director, Office of Health Services September 8, 2014
Began in 1966 Maryland Medicaid By FY 14, we provided full Medicaid benefits for over 1.2 million Marylanders Cost about $8.5 billion in FY13 in State and federal funds In FY 13 consumed about 24% of State budget (compared to 22% nationwide)
Maryland Medicaid Within federal parameters, Maryland designs its own: Eligibility standards Benefits package Provider requirements Payment rates Program administration through a State Plan or through waivers approved by the Centers for Medicare and Medicaid Services (CMS)
Medicaid expansion Health Reform ACA provides that all adults at or below 138% FPL are eligible for Medicaid beginning in 2014 (this includes the prior PAC population). 100% federally-funded 2014-2016; tapers down to 90% federally-funded by 2020 All new adults are enrolled in Managed Care Organizations.
1,200,000 Enrollment in Maryland Medicaid, by Coverage Category, 2006-2014 44,859 459,819 Medicaid ACA Expansion 1,000,000 PAC Elderly 800,000 Disabled 600,000 Other 400,000 MCHP Children Pregnant Women 200,000 - Jul-06 Jul-07 Jul-08 Jul-09 Jul-10 Jul-11 Jul-12 Jul-13 Jul-14 Source: DHMH, Office of Health Care Financing Parents/Caretaker 5
Managed Care in Maryland Medicaid
Maryland Medicaid Managed Care History Voluntary HMO program in the 1970s Mandatory enrollment in HealthChoice MCOs began in 1997 Over one million Marylanders - 83% of individuals on Medicaid are enrolled in an MCO Managed care is a way of financing and delivering health care aimed at improving quality and controlling cost
HealthChoice In managed care, Medicaid pays for some or all services at a prepaid rate capitation payment Medicaid contracts with managed care organizations (MCOs), which contract with a network of providers MCOs must meet a variety of quality and other standards, such as network adequacy 8
Managed Care Plans 9/6/2014* MCO Membership Amerigroup 272,320 JAI Medical Systems 25,655 Maryland Physician s Care 197,596 MedStar Family Choice 65,163 Priority Partners 243,059 Riverside (New in 2013) 24,029 United HealthCare 229,739 Kaiser (began June 2014 3,543
Managed Care Challenges States are trying to create more incentives for better quality of care Moving toward pay for performance Providing integrated care despite carve outs Pharmacy (specialty mental health and HIV/AIDs) Mental health since 1997 (Value Options) SUD services in Calendar Year 2015 Dental (DentaQuest is our dental ASO) LTC services
How are MCO s connected to Substance Use Disorder Programs? As a result of Behavioral Health Integration set to take effect January 2015, SUD services will be "carved-out" of Maryland Medicaid's HealthChoice managed care program and administered along with Mental Health Services by an Administrative Service Organization called Value Options. 11
What is an ASO? An Administrative Service Organization (ASO) is an organization contracted by the State to help manage services. ASOs do not provide health services but are responsible for: Helping consumers get proper services Handling authorizations Ensuring quality and appropriateness of services Processing claims Evaluating the system and compiling data for the management information system 12
Implementing BH ASO Maryland Medicaid
ASO History Persons needing specialty mental health care have received their health benefit through managed fee for service by an ASO under contract to the Mental Hygiene Administration since 1997 Starting in January 2015, Medicaid in collaboration with the Behavioral Health Administration will manage the ASO contract 14
ASO Transition 2012-2013 2013 - Feb 2014 July 2014 Sept 3 2014 Stakeholder Process Developed RFP Recommend for Award BPW Votes 15
Impact of Transition Starting on 1/1/15, submit claims to ASO Any willing, credentialed providers can participate in ASO There will be a requirement to notify ASO at beginning of treatment and there will be preathorization using ASAM critieria for certain services The ASO will: Offer trainings to providers on how to bill 16
The ASO will: Impact of Transition Automate the notification/ preauthorization process Offer trainings to providers on how to enroll patients and bill for services Medicaid and BHA will be involved in making sure this happens in a timely manner so that there is a smooth transition
RFP for Behavioral Health Worked with stakeholders to develop requirements for Integrated Behavioral Health ASO Goal was to take a good system and make it better by integrating and coordinating mental health and substance use services Challenge is to build in care coordination for physical health care
Big Picture on Transition Medicaid and BHA will work together with ASO and stakeholders to make sure that: Participants receive needed SUD services Providers are paid so that they can continue to provide care for participants It will take some time to work through the details and the process has just started because the new ASO was just approved
Big Picture on Transition There will be regular communication with the field during the next four months. If I can t answer questions today, I will take back and we will follow up with responses.
Keys to Successful Transition to ASO We are confident of a successful launch of the Behavioral Health ASO on January 1, 2015. This is in part because the winner of the bidding process is the incumbent and is already administering the specialty mental health system. This means that the eligibility, provider and claims processing interfaces with the Medicaid Management Information System (MMIS) are already in place.
First Key Implementation Task Enrolling SUD providers into the VO system. This task will be made easier by the fact that many providers are already enrolled in MMIS and therefore that data can be shared with the vendor and by the fact that VO has been administering SUD benefits for two of the current MCOs. VO also has commercial providers in Maryland that they plan to recruit to provide services for Medicaid patients.
Second Key Setting up notification/authorization screens and medical necessity standards for SUD services. This task is doable because VO has experience setting up authorization screens for mental health services and has used ASAM medical necessity standards in Maryland for SUD services.
Third Key Setting up a user friendly provider portal and training providers to use the authorization screens for SUD services. This will be a critical job, but it will be made easier by the fact that it will be automated and that all providers will only have to seek notification/authorization from one ASO rather than 8 MCOs. Providers will need to be trained concerning obtaining authorization, and billing for services
Fourth Key Developing a user friendly participant website which includes participant handbooks, provider directories, and education and outreach materials. There is already such a site for mental health services which can be strengthened and enriched with information for individuals with SUDs.
Fifth Key Coordinating care for individuals with cooccurring conditions - the State and VO will work with MCOs to provide data concerning individuals receiving behavioral health services.
Sixth Key Developing a state of the art call center for participants and providers. The current call center will be enhanced with additional staffing and with individuals that have expertise in SUD services.
Specific Question
Will Medicaid Apply for CMS accelerator grant? We would be open to exploring options under the CMS accelerator grant. That grant does not provide any funding to the State, but will pay for technical assistance to examine payment reform.
Questions?