Medicaid Managed Care Regulations MHP Contract Revisions and MHPAEA Parity Rule Webinar January 20, 2017

Introductions

Housekeeping Webinar Participants will be in listen only mode during the presentations. If you would like to ask a question, please submit your question using the GoToWebinar Question or Raise Your Hand feature. Please do not put your phone on hold. Meeting session will be recorded via GoToWebinar for notetaking purposes only. Recording will not be posted or made publicly available. Breaks are not scheduled. If you need a break, please feel free to excuse yourself.

Presentation Overview MHPAEA Parity Rule and Plan Review MHP Contract Amendment Q&A

MHPAEA Parity Rule and Review Process

Mental Health Parity Overview The Medicaid Mental Health Parity Final Rule applies the requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) to the Medicaid program. MHPAEA requires health plans to ensure that the financial requirements and treatment limitations that are applicable to MH/SUD benefits are no more restrictive than the predominant financial requirements and treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Medicaid Mental Health Parity Final Rule regulations are effective May 31, 2016 with an implementation date of October 2, 2017. Parity final rule requires that plans do not set more stringent limitations or requirements for MH/SUD benefits. Such limitations and benefits must be aligned with medical/surgical benefits, although med/sur benefits can be more restrictive. Implementation date of Oct but we will need to amend our contract as needed to come into compliance therefore we are looking at May 2017 to finalize.

Goals and Objectives The goal of the Final Rule Mental Health Parity project is to come into compliance with the Medicaid Mental Health Parity Final Rule regulations across the delivery systems (which includes both managed care and fee-for-service) with the Department. Four main components of Medicaid Mental Health Parity: Quantitative Financial Requirements and Treatment Limitations Benefits Classification Inpatient Outpatient Pharmacy Emergency Non-quantitative Treatment Limitations Disclosure Requirements

Quantitative Treatment Limitations (QTLs) QTLs are expressed numerically and may include number of visit limits, inpatient day limits, waiting period days, etc. Mental Health/Substance Use Disorder (MH/SUD) limit must be equal to or less restrictive than the predominant limit on medical/surgical benefits. Expressed numerically and easier to track and see the difference.

Non-Quantitative Treatment Limitations (NQTLs) NQTLs include medical management standards, formulary design, network tier design, provider admission and reimbursement rates, fail-first policies, and out-of-network access standards. Plans may not include NQTLs unless comparable standards are applied to medical/surgical benefits in the same category. NQTL standards may not be applied more stringently to MH/SUD benefits. NQTL evaluation focuses on equal processes not necessarily equal outcomes.

CMS Examples - NQTLs Refusal to pay for higher cost therapies until it can be shown that a lower-cost therapy is not effective (also known as fail-first policies or step therapies) Exclusions based on failure to complete a course of action Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage; and Standards for providing access to out-of-network providers Included in the CMS guidance on the final rule. These are possible NQTLs that may be in your plan and will need to be included in the survey.

DHCS Parity Review States must conduct an assessment, including: Authorization Policies and Procedures Treatment Limitations and Exclusions Provider Network, Credentialing and Contracting Medication Monitoring and Prescribing Practices Financial Requirements Disclosure Requirements

Parity Survey Survey will focus on NQTLs and QTLs that could possibly result in a parity conflict. Requesting each Plan respond to survey on current NQTLs and QTLs within each benefit classification DHCS will analyze survey results and conduct document review of Plan policies and procedures Survey is broken into 6 different areas which have different questions. Each question needs to include a response for each benefit classification that applies, for example if the question is about inpatient stays, you would respond in the inpatient area. For a question that is about referral to specialists, you will need to respond to all 4 benefit classifications. We will be giving continuous TA so please if you are stuck, email or call and we will provide assistance.

MHP Survey Applies to mental health and substance use disorder services Applies to children/youth and adult services Survey responses must be thorough, complete, and accurate Responses will be review as part of the DHCS parity compliance assessment Questions are yes/no and short answer

Authorization Review Prior Authorization refers to authorization and approval of services prior to service delivery, which may include review of medical necessity criteria before services begin. Concurrent Authorization refers to daily stay review for inpatient and residential services or per treatment (or set of treatments) review for outpatient services. Retrospective Authorization refers to post-service delivery review and authorization of services, usually via request for payment/claims processing. Pre-Notification refers to notification of services prior to or concurrently with service delivery for a beneficiary.

Authorization by Service Category Inpatient services Psychiatric health facility services Residential services Outpatient services Crisis stabilization services

Authorization Survey Questions Does the COUNTY require prior authorization for any outpatient services? MH ☐ SUD☐ Does the COUNTY limit authorization to a specific number days for outpatient services? Does the COUNTY conduct concurrent authorization review for any outpatient services? Does the COUNTY conduct retrospective authorization review for outpatient services? Are the COUNTY’s P&Ps for authorization more restrictive than the minimum state or federal requirements? What is the COUNTY’s process, strategy, evidentiary standards, and/or other factors (e.g., panels of experts, evidentiary standard based on clinically appropriate standards, etc.) used to determine authorization for outpatient services? COUNTY Response: What is the role of psychiatrists and/or physicians in authorization of outpatient services?  

Authorization Documentation A list of all services requiring prior authorization Policies and Procedures (P&Ps): Authorization of Inpatient Services Hospital Utilization Review Committee (URC) Policies and Procedures (P&Ps): Authorization of Inpatient Services Policies and Procedures (P&Ps): Authorization of Outpatient Services Policies and Procedures (P&Ps): Authorization of Residential Services Policies and Procedures (P&Ps): Authorization Criteria and/or Evidentiary Standards Authorization Review and Chart Audit Tools Provider Manual Network Provider Boilerplate Contract (for individual and organizational providers)

Case Management and Care Coordination Are there any limitations imposed on case management services? MH ☐ SUD☐ If yes, please specify: COUNTY Response:   Are there any limitations imposed on care coordination services?

Case Management and Care Coordination Documentation P&Ps: Case Management P&Ps: Care Coordination Provider Manual Practice Guidelines

Client Plans What is the COUNTY’s standard timeframe for completion of the client plan? COUNTY Response:   What is the COUNTY’s standard timeframe for updating the client plan? What is the COUNTY’s procedure for periodically reviewing the client plan?

Client Plan Documentation P&Ps: Client Plans Provider Manual

Progressive Therapy/Step Therapy Does the COUNTY limit treatment or service options based on failure to complete prior treatments and/or due to client non-compliance? MH ☐ SUD☐ If yes, what criteria are used to make such determinations? COUNTY Response:   Does the COUNTY require a beneficiary to first try one form of treatment before progressing to other treatments? If yes, what treatments or services? Is the determination at all based on the cost of the treatment?

Progressive Therapy Documentation P&Ps: Selecting Interventions P&Ps: Progressive Therapies Practice Guidelines Provider Manual

Provider Network What are the COUNTY’s current procedures for credentialing licensed providers (e.g., Psychiatrists, Psychologists, LCSW, LMFT, LPCC, RN)? MH ☐ SUD☐ What are the COUNTY’s current procedures for credentialing non-licensed providers? Does the COUNTY have multiple network tiers (e.g., preferred providers)? Does the COUNTY restrict the types of provider specialties that can provide certain mental health and/or substance use disorder services? If yes, what provider types and services are restricted? COUNTY Response:   Does the COUNTY require beneficiaries to access services in a specific geographic location/area? If yes, under what circumstances are such restrictions imposed? What are the COUNTY’s limitations regarding access to out-of-network providers?

Provider Network Documentation P&Ps: Credentialing Provider Manual

Medication Prescribing & Authorization Does the COUNTY require labs, drug testing, or any other patient compliance monitoring for the purposes of prescribing certain types of medications? MH ☐ SUD☐ If yes, list applicable medications. COUNTY Response: What criteria are used for prescribing medications?   What are the COUNTY’s procedures for medication monitoring?

Medication Documentation P&Ps: Medication Monitoring P&Ps: Prescribing Practices P&Ps: Medication Assisted Treatment Practice Guidelines: Medication

Financial Requirements What are the COUNTY’s methods for determining usual, customary, and reasonable charges? COUNTY Response:   What are the COUNTY’s methods for determining reimbursement rates for providers? Does the COUNTY have any group size rules for billing purposes? MH ☐ SUD☐ Does the COUNTY impose any cost-sharing requirements? If yes, under what circumstances?

Financial Requirements Documentation P&Ps: Provider Claims Processing P&Ps: Group Size Limitations P&Ps: Cost Sharing P&Ps: Rate Development

Disclosure Requirements Does the COUNTY make the criteria for medical necessity determinations available to any current or potential beneficiaries upon request? MH ☐ SUD☐ Does the COUNTY make the criteria for medical necessity determinations available to contracting providers upon request? Documentation: P&Ps: Medical Necessity Determinations P&Ps: Information Dissemination

Survey Timeline Parity Webinar – January 20th Survey Monkey Sent – January 24th Technical Assistance Call – January 26th Survey Responses Due – February 3rd Documentation Due – February 17th DHCS Analysis – Spring 2017 DHCS Compliance Deadline – October 1st

Resources Federal Register, Volume 81, No 61, March 30, 2016 FAQs About Affordable Care Act Implementation of Part 34 and Mental Health and Substance Use Disorder Parity Implementation, October 27, 2016. DOL, HHS and Treasury. Warning Signs- Plan or Policy Non-Quantitative Treatment Limitation (NQTLs) That Require Additional Analysis to Determine Mental health Parity Compliance. DOL and HHS.

MHP Contract Amendment

MHP Contract Amendment Final Rule Amendments Alignment with MCP Contract Format and Content §438.3(a) requires DHCS to submit the contract to CMS for approval 90 days prior to effective date Revisions include mandated compliance with managed care final rule requirements

Revised MHP Contract Outline Contents Subject Matter Overview Exhibit A – Scope of Work Service Overview Service Locations and Hours Project Representatives Attachment 1 – Organization and Administration of the Plan Personnel Requirements Medical Necessity Administrative Responsibilities Implementation Plan Training Requirements Attachment 2- Financial Information Financial Requirements Claiming Cost Reports Financial Audits Attachment 3- Management Information System MIS Capability Encounter Data Reporting HIPAA Requirements

Subject Matter Overview Contents Subject Matter Overview Attachment 4 – Quality Improvement System General Requirements Quality Improvement Committee Written Description of QI Program QI Work Plan Requirements EQR Requirements Practice Guidelines Attachment 5- Utilization Management Program Utilization Management Requirements Authorization Procedures Review of Utilization Data Attachment 6 – Provider Network Network Capacity & Composition Time and Distance Standards Timely Access Subcontractors/Network Providers Ethnic and Cultural Composition Credentialing Site Reviews

Subject Matter Overview Contents Subject Matter Overview Attachment 7– Provider Relations Provider Monitoring Provider Grievances and Appeals Provider Manual Provider Training Attachment 8 – Documentation Requirements Documentation Requirements Attachment 9 – Access and Availability of Services Access Requirements and Standards Cultural Competence Plan Linguistic Access Requirements Out-of-network Providers Attachment 10 – Scope of Services Covered Services Medically Necessary Services Therapeutic Behavioral Services Day Program Requirements

Subject Matter Overview Contents Subject Matter Overview Attachment 11 – Care Coordination and Continuity of Care Care Coordination MCP MOU Requirements Attachment 12 – Beneficiary Rights Member Rights and Responsibilities Written Informing Materials Network Provider Selection Attachment 13 – Beneficiary Problem Resolution Grievance and Appeal System and Procedures Grievance and Appeal Logs and Reporting Requirements Notices of Adverse Benefit Determination State Fair Hearings

Subject Matter Overview Contents Subject Matter Overview Attachment 14 – Reporting Requirements Reporting requirements and deadlines Attachment 15 – Contract Compliance Plan & Deliverables Contract Compliance Plan Deliverables Exhibit B – Budget Details and Payment Provisions Payment Provisions Budget Contingency Clause FFP Claims Adjudication Process Administrative Reimbursement Exhibit E – Attachment 1 - Definitions Definitions Exhibit E – Attachment 2 – Program Terms and Conditions Governing Law Amendment Process Delegation Authority of the State Sanctions

Contract Deliverables Must be submitted to CMS with contract for approval Demonstrate compliance with final rule requirements Documentation examples: Updated Policies and Procedures Organization Charts Provider Contract Boilerplates Provider Manuals MOUs with Managed Care Organizations MHPs must submit identified deliverables to DHCS – Spring 2017

Estimated Contract Timeline MHP Webinar – January 20th CBHDA/DHCS Final Rule Workgroup – February 15th MHP Review – February 2017 DHCS to Finalize and Submit to CMS– April 2017 MHP Deliverables Due – May 2017 Submit Deliverables to CMS – May 2017 Contract Effective – July 2017

QUESTIONS?

Contact Information Autumn Boylan, System Compliance Chief Autumn.Boylan@dhcs.ca.gov Brian Keefer, Subject Matter Expert Brian.Keefer@dhcs.ca.gov 916-650-0486 Victoria King Watson, Assistant Division Chief, SUD PPFD Victoria.King-Watson@dhcs.ca.gov 916-650-0523