CCBHC Prospective Payment System (PPS) Technical Assistance (TA) Session 5 Webinar: Identification of Special Populations February 25, :30-4:00pm ET

I.Welcome II.Identification of Special Populations a.Goals of TA session b.Special populations in the context of PPS rate determination c.Determining PPS-2 rates for special populations d.Proposed CMS criteria for designating special populations III.Questions IV.PPS Webinar Schedule Webinar Agenda 2

Provide information about the importance of selecting special populations (SP) for PPS-2 rate development Provide guidance states may use for the determination of SP groups Goals of this PPS Technical Assistance Webinar 3

States electing to use CC PPS-2 will designate groups of clinic users with certain conditions as SPs. Separate CC PPS-2 rates will be developed for these SPs to reflect the higher cost of providing care to individuals identified as part of a SP. Special Populations in the Context of PPS Rate Determination 4

Determining PPS-2 Rates for Special Populations 5 1. Scope of Services 3. Providers States must identify and analyze utilization and cost data associated with the SP. Establishment of separate monthly rates for SPs and non-SP clinic users is intended to reimburse CCBHCs for higher costs associated with care to SPs.

Formula for determining rates for SPs: Determining PPS-2 Rates for Special Populations (continued) 6

Identifying Characteristics of Populations Requiring More Intensive & Costly Services 7 States should consider the clinical classifications with regard to cost and utilization patterns associated with patients within a SP Ideally, states will select and define SPs using an approach that groups individuals with similar patterns −Goal is to minimize variance between CC PPS-2 payment and actual cost of services for a given individual

Under the 223 Demonstration, states have flexibility to determine SPs. Using data from MMIS and in consultation with clinics states will identify the characteristics of populations requiring more intensive and costly services. Steps for Designating Special Populations 8

Identifying Characteristics of a SP: SMI and SED 9 SAMHSA defines individuals with serious mental illness (SMI) and serious emotional disturbance (SED) on basis of diagnosable disorders and functional impairment* *DSM-IV or ICD-10-CM Children & Adolescents with SED Individuals up to age 18 who currently or in past year had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified with the DSM-IV, resulting in functional impairment that substantially interferes with or limits child’s role or functioning in family, school, or community activities. Adults with SMI Individuals 18 years and over who currently or in past year had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified with the DSM-IV, resulting in functional impairment that substantially interferes with or limits one or more major life activities.

Exclusions from SAMHSA definition of SMI and SED: – Substance-related disorders, developmental disorders, dementias, and mental disorders due to a general medical condition – Unless they co-occur with another diagnosable SMI or SED Appendix A lists diagnoses considered SMI or SED SAMHSA definition includes functional impairment – Relying on a list of diagnoses will not satisfy intent of SAMHSA definition but states are not bound by it – Possible solution to consider functioning: use Supplemental Security Income and Social Security Disability Insurance designations to indicate functional impairment Identifying Characteristics of a SP: SMI and SED 10

Identifying Characteristics of a SP: Alternative Use of SMI and SED 11 Alternative options for categorizing SPs – Adults with significant substance abuse disorders – Adults with SMI and co-occurring SUDs

Individuals experiencing a first episode of psychosis Individuals with a recent history of hospitalization related to behavioral health conditions Homeless individuals Other Potential SP Classifications 12

Potential strategies to identify SPs that warrant separate PPS-2 rates: 1.Identify potential SP classification groups for consumers served by CCBHC 2.Compute average cost per month for each different population group 3.Evaluate whether the proposed SP costs warrant a distinct CC PPS-2 rate Identifying Special Populations: Data Sets and Process 13

Availability and application of cost and utilization data Each state will need to decide: – What data will be used for identifying SPs (e.g., past year, past 6 months) States should have a clearly defined process for setting clinic-specific payment rates for each SP category using historical data and for determining how patients are categorized Identifying Special Populations: Other Considerations 14

States should consider the following questions: 1.Is there enough experience to support setting a separate rate for a given SP within the CCBHC? 2.Are service patterns consistent throughout the state, or do they vary by region or CCBHC? Identifying Special Populations: Other Considerations (cont.) 15

States must communicate to CCBHCs a clear protocol for categorizing an clinic user into the appropriate SPs Include instructions where a clinic user may fall into multiple SP classifications Include guidance regarding the protocol where a clinic user moves to a new classification (another SP or the standard rate) Promotes billing of the correct CC PPS-2 rate Classification of Patients by SP 16

Questions 17

Mailboxes – CMS mailbox for PPS guidance-related questions: – CMS mailbox for Quality Based Payment-related questions: 223 PPS TA SharePoint Site Link Q&As posted online Collaboration Tools 18

Webinar Topic Date Outlier PaymentsThu 3/10/16, 2:30-4pm ET Demonstration ClaimingThu 3/24/16, 2:30-4pm ET Managed CareThu 4/7/16, 2:30-4pm ET Quality Bonus PaymentsThu 4/21/16, 2:30-4pm ET Case Study/OpenThu 5/19 & 6/16, 2:30-4pm ET PPS Webinar Topics & Schedule *Topics and dates are subject to change 19