John R. Kasich, Governor Tracy J. Plouck, Director All Ohio March 24, 2017
Ohio Medicaid Behavioral Health Redesign Initiative The Redesign Initiative is an integral component of Ohio s comprehensive strategy to rebuild community behavioral health system capacity The Initiative is based on key Medicaid behavioral health reforms implemented in four steps: Elevation Financing of Medicaid behavioral health services moved from county administrators to the state. Expansion Ohio implemented Medicaid expansion to extend Medicaid coverage to more low-income Ohioans, including 500,000 residents with behavioral health needs. Modernization ODM and OhioMHAS are charged with modernizing the behavioral health benefit package to align with national standards and expand services to those most in need Integration Post benefit modernization, the Medicaid behavioral health benefit will be fully integrated into Medicaid managed care. 2
3 Ohio Medicaid Behavioral Health Redesign Initiative - Where We Are Today Elevation Completed as of July 1, 2012. Expansion Completed as of January 1, 2014. Modernization Underway, ODM and OhioMHAS are modernizing the community behavioral health benefit package to align with national standards and expand services to those most in need. Implementation on target for July 1, 2017. Integration Post benefit modernization, the community Medicaid behavioral health benefit will be fully integrated into Medicaid managed care. Implementation on target for January 1, 2018.
Align with national coding standards Improve transparency into what Ohio Medicaid is buying Rendering provider type Access to more codes: more granular info Add some specific services (ACT, IHBT) Align with ASAM levels of care for specific substance use disorder services
5 Supporting Continued Access Ensure Sustainability Provide Training and Support Encourage Organizational Awareness Ensure Access All changes and stakeholder engagement are intended to ensure changes to the Behavioral Health program are sustainable into the future Numerous training and technical assistance opportunities have and will be provided to support the goal of sustainability Organizations must also be attentive to changes and adjust business models where necessary The state will collaborate with boards, providers, and other local entities to ensure ongoing access to services and continuity of care for individuals
Behavioral Health Benefits
36 ASAM Levels of Care The green arrow represents the scope of Ohio s Medicaid BH Redesign.
8 Medicaid Substance Use Disorder Benefit Pre July 1, 2017 Outpatient Residential Ambulatory Detoxification Assessment Case Management Crisis Intervention Group Counseling Individual Counseling Intensive Outpatient Laboratory Urinalysis Medical/Somatic Methadone Administration Ambulatory Detoxification Assessment Case Management Crisis Intervention Group Counseling Individual Counseling Intensive Outpatient Laboratory Urinalysis Medical/Somatic
9 Medicaid Substance Use Disorder Benefit July 1, 2017 Outpatient Adolescents: Less than 6 hrs/wk Adults: Less than 9 hrs/wk Intensive Outpatient Adolescents: 6 to 19.9 hrs/wk Adults: 9 to 19.9 hrs/wk Partial Hospitalization Adolescents: 20 or more hrs/wk Adults: 20 or more hrs/wk Residential Assessment Psychiatric Diagnostic Evaluation Counseling and Therapy Psychotherapy Individual, Group, Family, and Crisis Group and Individual (Non-Licensed) Medical Medications Buprenorphine and Methadone Administration Urine Drug Screening Peer Recovery Support Case Management Level 1 Withdrawal Management (billed as a combination of medical services) Assessment Psychiatric Diagnostic Evaluation Counseling and Therapy Psychotherapy Individual, Group, Family, and Crisis Group and Individual (Non-Licensed) Medical Medications Buprenorphine and Methadone Administration Urine Drug Screening Peer Recovery Support Case Management Additional coding for longer duration group counseling/psychotherapy Level 2 Withdrawal Management (billed as a combination of medical services) Assessment Psychiatric Diagnostic Evaluation Counseling and Therapy Psychotherapy Individual, Group, Family, and Crisis Group and Individual (Non-Licensed) Medical Medications Buprenorphine and Methadone Administration Urine Drug Screening Peer Recovery Support Case Management Additional coding for longer duration group counseling/psychotherapy Level 2 Withdrawal Management (billed as a combination of medical services) Per Diems supporting all four residential levels of care including: clinically managed medically monitored two residential levels of care for withdrawal management Medications Buprenorphine and Methadone Administration Medicaid is federally prohibited from covering room and board/housing Level 2 Withdrawal Management (billed as a combination of medical services OR 23 hour observation bed per diem
10 BH Redesign Changes Support the Treatment of Mental Illness Efforts Expanding MH Benefit package Adding family psychotherapy both with and without the patient Adding primary care services, labs & vaccines Adding coverage for psychotherapy, psychological testing Adding evidence based/state best practices: Assertive Community Treatment - adults with SPMI Intensive Home Based Treatment - youth at risk of out of home placement Expanding community based rehabilitation: Therapeutic Behavioral Services & Psychosocial Rehabilitation & maintaining coverage of CPST Maintaining prior authorization exemption for second generation antipsychotic medications when dispensed by physicians with a psychiatric specialty and in the standard tablet/capsule formulation Expanding eligibility for children s respite care
Expanded Medicaid Managed Care Respite Service On February 1, 2017, Medicaid respite services became available for children with mental health needs who are enrolled in Medicaid Managed Care. The definition of respite services, eligibility criteria and provider qualifications are described in Ohio Administrative Code rule 5160-26-03 which became effective February 1, 2017. Requests for coverage of respite services must be made to and approved by the child s managed care plan in accordance with the OAC rule requirements, as this service is fully carved in. A MITS Bits detailing this update was released on Feb. 6 th and can be found here. 11
Budget & Stakeholder Process
13 Budget Model Process Provider survey Feedback from stakeholders State purchasing decisions Clinical judgment about service changes Assumptions New Rate Structure Not one-to-one correspondence with former structure Estimates were made All MH and SUD SFY 2014 service utilization was mapped Additional below the line adjustments for ACT and urine drug screening; separate utilization mapping process for SUD residential Utilization mapping plus added spend
14 Budget Model Assumptions The Budget Model is an Educated Estimate Overall estimate of the rate restructuring on the State budget and different sectors of the provider community. Does not reflect any one provider s expected budget. Forecasting the expected aggregate results at the system level. Assumptions will not match each individual Provider s experience Iterative process with initial assumptions informed more heavily by survey results from 77 providers; subsequent changes as a result of stakeholder input. The model will overstate or understate revenues for a particular provider. The model will not reflect any individual provider s revenues. Different providers have given opposite feedback on the same services (e.g., 99215)
6 BH Redesign Input Opportunities Stakeholders were given numerous opportunities to provide feedback as well as many training opportunities to understand the changes coming to Ohio s BH system 2015 2016 2017 May - Jul Aug - Oct Nov Dec Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. Apr. Stakeholder Meetings Monthly meetings with the Benefit & Service Development Workgroup / Core Team between May 2015 Jun 2016 B&SD meeting 8/23 B&SD meeting 10/6 B&SD meeting 11/30 B&SD meeting 2/15 B&SD meeting 4/19 Trainings CPT code training 4/14 BH 101 Trainings 7 sessions in April & May BH Regional Trainings 10 sessions in July & August CPT code trainings 3 sessions in August & September BH 201 Trainings 8 sessions in October & November OTP Webinar January BH 301 Trainings 5 sessions in March & April
16 Behavioral Health Redesign Updates from e-newsletter released March 6 th The following policy changes have been made in response to stakeholder feedback: 1 For documentation, rules will include the ability to use structured drop down and check list options that support individualized clinical documentation. 2 Inclusion of Place of Service 23 Emergency Room-Hospital for the provision of crisis services to individuals in an emergency room. 3 Support of RNs and LPNs to provide nursing services within their scope of practice as defined by the Ohio Board of Nursing. The Ohio Board of Nursing has purview over the scopes of practice for RNs and LPNs and has published guidance on this topic which is available on their website here: http://www.nursing.ohio.gov/pdfs/practice/rn_and_lpn_scope_of_practice.pdf. 4 ODM will be clarifying the rule language related to staffing requirements for the American Society of Addiction Medicine (ASAM) residential levels of care.
17 Behavioral Health Redesign Updates from e-newsletter released March 6 th, cont d The following policy changes have been made in response to stakeholder feedback: 5 Removal of TBS and PSR from the counseling tab of the Behavioral Health Redesign Workbook and moving them to the recovery supports tab. 6 Urine drug screening (UDS) collection and handling (H0048) - ODM and OhioMHAS will be increasing the payment rate for UDS from the current $11.48 to $14.48. 7 Inclusion of Place of Service 99 Community to account for instances where services are provided in a setting when there isn t a representative place of service code available. 8 ODM will open Medicaid Information Technology System Trading Partner testing in early May.
18 New Behavioral Health Redesign Policy Updates Policy changes set out below address the following objectives: Maintain and improve access for those that have complex behavioral health needs and chronic addictions Maximize existing and available workforce Prevent cost shifting to other systems Decisions 1 2 3 Allow QMHS+3 to provide MH Day Treatment Clarify nursing services guidance Provide TBS/PSR Prorate
19 Behavioral Health Redesign Operational Updates Policy changes set out below address the following objectives: Ensure timely payment Extend the testing timeline to ensure successful implementation Guarantee investment in additional service capacity Decisions 1 2 3 Modify and expand the testing timeline Establish a rapid response team Monitor implementation
BH Redesign Newsletter Released March 17, 2017 Qualified Mental Health Specialist (QMHS)+3 years may provide MH Day Treatment QMHSs with a minimum of 3 years of experience (without a Bachelor s or Master s degree) in a relevant field as determined by the employing agency may render MH Day Treatment. This includes MH Day Treatment per hour up to two hours (H2012 UK HQ) and MH Day Treatment per diem (H2020 UK). Medicaid Information Technology System (MITS) Trading Partner testing The timeline for trading partner EDI file testing has been expanded from two weeks to six weeks. Trading partners will be able to start testing in early May 2017. Therapeutic Behavioral Service (TBS) and Psychosocial Rehabilitation (PSR) TBS/PSR services rendered in an office (POS 11) or a community mental health center (POS 53) for more than 90 minutes provided by the same agency, to the same recipient, on the same calendar day will be at 50% of the rate. TBS/PSR services provided in all other places of services will be paid at 100% of the rate after 90 minutes. Rapid Response Team State will establish a Rapid Response team that will be available beginning in July, 2017 to provide technical assistance 6 days a week for any issues related to claims payment or processing time. Nursing Services Monitoring Implementation There will be no limits to medically necessary nursing services. There will no longer be a limit of 24 hours (96 units) for Mental Health or SUD Nursing services per patient, per calendar year. ODM and OhioMHAS are implementing a plan to monitor the Behavioral Health Redesign. The State will monitor claims payment and processing times to ensure that a timely payment mechanism is in place when we transition to the new system in July, 2017. Please refer to http://bh.medicaid.ohio.gov/newsletters for further details. 20
Update on Medicaid Policy Re: Institutions for Mental Disease (IMD)
IMD Policy Update Federal Policy State Policy Guidance Goals of Initiative (implemented July 1, 2017) With implementation of 42 C.F.R. 438.6, the State may make a monthly capitation payment to an MCP for a member age 21 through 64 receiving inpatient treatment in an Institution for Mental Disease (IMD). Length of stay in the IMD is for a short term stay of no more than 15 days during the period of a monthly capitation payment The State determines that it is medically appropriate The approved services are authorized and identified in the MCP contract and will be offered to enrollees as the option of the MCP and enrollee Increased access to intensive mental health treatment Services closer to home Community alternatives Fewer re-admissions Expands provider network Continuity of care Coordination of care Note: State hospitals are a safety net for inpatient psychiatric care. 22
23 IMD Policy Update Communication The State will work with MCPs to communicate IMD policy updates: Trainings / forums hosted by MCPs FAQ document under development MITS Bits under development
Managed Care
Medicaid Managed Care Plans - Today BH Services are CARVED OUT Until 1/1/18 Ohio Medicaid recipients enrolled in a Medicaid managed care plan - Buckeye, CareSource, Molina Healthcare of Ohio, Paramount Advantage or UnitedHealthcare can receive community behavioral health services through any participating Medicaid BH Provider agency. One Exception: Respite Coordinated or associated primary health care, (pharmacy, laboratory services) are the responsibility of MCPs. Check for any needed prior authorization. Paramount is a Medicaid Managed Care Plan but not a MyCare plan 25
MyCare Ohio Managed Care Plans - Today BH Services are CARVED IN Ohio Medicare and Medicaid recipients enrolled in a MyCare Ohio plan - Aetna, Buckeye, CareSource, Molina Healthcare of Ohio, or UnitedHealthcare - receive community behavioral health services through their MyCare Plan. Providers will need to be contracted with MyCare Plan and MAY need prior authorization for certain services Aetna is a MyCare plan but not a Medicaid Managed Care Plan 26
Timeline: 2016 2019 Transition of Care for Managed Care 18 months of continuity Ongoing planning FFS for 6 months FFS policies continue under MCPs for 12 months Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan 2016 2017 2018 2019 Transition to new code set for FFS and MyCare Managed Care Carve-In Plans will follow state benefit administration policies for one year after carve-in. MCP year is administered on a calendar year basis (Jan-Dec). Any prior authorizations approved by Medicaid prior to carve-in will be honored by the plans, and the plans will assume the responsibility for the prior authorization process when authorizations under FFS expire. Milestone 27
28 Managed Care Carve-In Next Steps Next Steps Develop provider agreement language Release communications (e.g., FAQs, MITS Bits) Hold provider forums Continue Stakeholder Benefit and Service Development Workgroup meetings Carve-in slated for January 1, 2018
IT Resources and EDI File Testing (Fee for Service)
IT Resources 127
128 IT Resource Documents BH.Medicaid.Ohio.Gov Services Billable to Medicare (Final Version) - Identifies those codes that require third party billing as well as those that do not Supervisor Rendering Ordering Fields - Identifies what information is in these fields for all CPT and HCPCS codes Services Crosswalk - Details what codes can be billed on same date of service ACT-IHBT - What is allowed to be billed with these two new services, what is not allowed and what requires prior authorization Dx Code Groups - Allowable diagnoses for behavioral health services Limits, Audits and Edits - Includes benefit limits as well as audits to limit some combination of services on same day EDI/IT Q-and-A - Contains responses to questions received from EDI/IT work group
EDI File Testing Early May: Trading partners can begin testing EDI file submissions to MITS. MyCare Plans open testing. May-June: Providers continue preparation for go live. More detailed information will be forthcoming via MITS Bits 32
33 Checklist for July 1, 2017 BH Providers should complete these steps prior to Go Live for BH Redesign: Practitioners Required to Enroll in Medicaid Obtain NPI Complete your Ohio Medicaid enrollment application by April 2017 see instructions and webinar training on this posted here http://bh.medicaid.ohio.gov/training Respond quickly to any communication from Ohio Medicaid regarding your application Once enrolled, the practitioner must be affiliated with their employing agency Enroll by April 1, 2017 to guarantee completion by July 1, 2017 Medicare: Agencies and Practitioners should enroll no later than May 2017 to ensure readiness for the July 1, 2017. See MITS BITS here: http://mha.ohio.gov/portals/0/assets/planning/macsisormits/revisedmits-bits-medicare-enrollment-4-22-16_rev.pdf
34 Checklist for July 1, 2017, slide 2 BH Providers should complete these steps prior to Go Live for BH Redesign: IT Systems Existing trading partners may begin submitting test EDI files in early May. New trading partners will be accepted after the migration has been completed. Trading partner testing region will be open 24/7. See extensive IT guidance on BH.Medicaid.Ohio.gov and Provider staff and your IT System Designers should participate in IT Work Group Meetings Train all levels of staff on BH Redesign changes Attend trainings Watch webinars Study documents at BH.Medicaid.Ohio.gov
Next Steps
36 2017 BH Redesign Timeline December January February March April May June July State Plan Amendments In segments by Late Feb/ Early March: MRO & OLP submission MRO & OLP approval expected sometime in early summer Rules 1-31-17: Shared Rules Package with stakeholders Early March: CSIO process begins 4-14-17: Deadline for Rules filed with JCARR 7-1-17: BH Rules effective date Manuals 12-16-16: Final OTP Manual (& webinar) 1-31-17: Shared Version 1.2 7-1 BH Manual 7-1-17: Final 7-1 BH Manual effective date MITS System Design 1-31-17: Reviewed and approved the HPE BRD Technical changes to be made to MITS for 7-1 preparations IT Specs 1-25-17: Stakeholder Engagement EDI/IT workgroup meeting 2-15-17: BSD Work Group meeting Documents are available so providers, MCPs and IT vendors can build their systems Targeted trainings
Upcoming Stakeholder Engagement 2017 March April May June July Stakeholder Meetings Bi-Weekly IT work group meetings Benefit & Service Development work group meeting 4/19 Benefit & Service Development work group meeting 6/7 Bi-weekly IT meetings ongoing through May Training and Technical Assistance BH Fundamentals Trainings 3/20 Toledo, 3/21 Cleveland, 3/22 Cincinnati, 3/28 Zanesville, 4/7 Columbus Prior Authorization Webinar May 2017 Ongoing Managed Care Forums Technical Aspects of Medicaid Claim Adjudication Webinar June 2017 Post go-live, Technical Assistance available 6 days a week Technical Assistance available on an on-going basis 37
38 Non-Medicaid Funded Supports Training Strategy January 2017 February March ADAMH Boards Updated Fiscal 040 electronic forms to the board/ OhioMHAS workgroup Finalize any outstanding issues with boards Share materials, instructions, and supporting appendices so boards can use them to inform budgeting process Face-to-face training will be recorded (video and audio) and made publically available
39 Next Steps Next Steps Rules process, Trainings and Stakeholder Meetings Submit new/updated Ohio Administrative Code rules via the Common Sense Initiative and the Joint Committee Agency on Rule Review public processes Hold BH Fundamentals trainings throughout March and April Meet with Benefit and Service Development Work Group April 19, 2017
40 ODM and OhioMHAS Rules & Process ODM Rules ODM has drafted Ohio Administrative Code rules authorizing the BH Redesign including Medicaid service definitions, coverage, payment policy, and recipient and provider eligibility. ODM s rules also propose consolidating mental health and substance use disorder services into a single chapter. In March, ODM s rules will be submitted to the Common Sense Initiative Office (CSIO) and Joint Committee Agency on Rule Review (JCARR) public rule filing process. The draft rules are available here. OhioMHAS Rules OhioMHAS s draft rules have been updated and submitted to the CSIO and JCARR public processes. They support a reframing of OhioMHAS certification with emphasis on recognizing practitioner scopes of practice as defined by Ohio professional regulatory boards. Rules also take into account patient health, welfare and safety standards. They also finalize the unification of ODADAS and ODMH regulatory frameworks into a single chapter. Rules are grouped into two categories: (1) those related to BH redesign and (2) those related to agency consolidation. Both groups of rules can be accessed here.
ODM and OhioMHAS DRAFT Rules Eligible providers Coverage and limitations Reimbursement ODM Assertive community treatment (ACT) Intensive home based treatment (IHBT) Mental health day treatment Therapeutic behavioral services (TBS)/Psychosocial rehabilitation (PSR) Substance use disorder treatment services (ASAM) Targeted case management Nursing Crisis intervention Other licensed professionals (OLP) CPST (no policy change) Applicability Progress notes General services OhioMHAS Mental health day treatment Residential and inpatient SUD services Crisis intervention Case management Therapeutic behavioral services (TBS)/Psychosocial rehabilitation (PSR) Methadone administration Intensive home based treatment (IHBT) Assertive community treatment (ACT) Interactive videoconferencing CPST (no policy change) ODM and OhioMHAS Rules are now available for review on the BH Redesign site and OhioMHAS site. 41
Behavioral Health Redesign Website
Behavioral Health Redesign Website Go To: bh.medicaid.ohio.gov Sign up online for the BH Redesign Newsletter. Go to the following OhioMHAS webpage: http://mha.ohio.gov /Default.aspx?tabid=154 and use the BH Providers Sign Up in the bottom right corner to subscribe to the BH Providers List serve. 43