Drug Medi-Cal Organized Delivery System Waiver

DMC Benefits Prior to ACA Mandatory Population Only Modalities Outpatient Drug Free (ODF) - all mandatory populations Narcotic Treatment Programs (NTP) - all mandatory populations Residential (perinatal only in non-IMDs) Intensive Outpatient Therapy (IOT) - perinatal only

ACA Expansion Increased Eligible Beneficiaries (Expanded Population) CA chose to expand modalities IOT (for Mandatory and Expanded Populations) Residential (for Mandatory and Expanded Populations)

ACA Expansion Residential Services Residential needed in the continuum of care Restricted due to the Institute for Mental Disease (IMD) exclusion Ninety percent of California’s residential bed capacity is considered an IMD Clients in IMD’s restricted from all MediCal services Without the DMC-ODS Waiver Pilot, California cannot provide residential services

DMC Organized Delivery System Waiver The goal is to improve Substance Use Disorder (SUD) services for California beneficiaries Authority to select quality providers Consumer-focused; use evidence based practices to improve program quality outcomes Support coordination and integration across systems 1. As of November 21 2014, DHCS is proud to report that over 270,864 people opted in using Express Lane Enrollment (ELE) and are now receiving Medi-Cal benefits. 2. DHCS conducted another mailing to approximately 380,000 individuals in October and November 2014. 202,000 individuals are newly enrolled in CalFresh; therefore, could be newly eligible for ELE. The remaining 178,000 individuals are those who did not opt in from the first ELE mailing in February 2014. Health Care Options is doing further outreach by phone to those individuals who did not respond to the letters sent in 2014.

DMC Organized Delivery System Waiver Reduce emergency rooms and hospital inpatient visits Ensure access to SUD services Increase program oversight and integrity Provide availability of all SUD services Place client in the least restrictive level of care Total application portal transactions submitted as of 11/08/14: 206, 954 Individuals approved for PE: 157,279 Individuals denied for PE: 32,162 (The denied amount includes multiple portal submission attempts.) Three main reasons individuals are denied for PE: Over income limit Found eligible for Medi-Cal Has coverage through Covered California Total web portal transaction issues: 17, 513 Pending Caseload: Assumptions: Contains Unique, De-Duplicated Medi-Cal Applicants in Pending Status Counted as month of submission Excludes cases under 45 days "Of the pending, the following additional reductions may be realized: 1. Approximately 20,000 (under age 19) with pending eligibility via the county access using presumptive eligibility. 2. Minimally 40,000 to be administratively denied." Source: CalHEERS

Current Kings Co. DMC Funded Services Champions Kings View Eminence WestCare Outpatient Intensive Outpatient Residential-Perinatal Only

DMC Organized Delivery System Waiver DMC Services SPA 13-038 ( Non-Waiver Opt-in Waiver Outpatient/Intensive Outpatient X NTP Residential X (one level) Withdrawal Management Recovery Services Case Management Physician Consultation Additional MAT X (optional)

WHAT IS ASAM? The ASAM Criteria, formerly known as the ASAM patient placement criteria, is the result of a collaboration that began in the 1980s to define one national set of criteria for providing outcome-orientated and results-based care in the treatment of addiction. The ASAM Criteria is most widely used and comprehensive set of guidelines for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions.

Benefits of using the ASAM Criteria The ASAM Criteria provides a consensus based model of placement criteria and matches a patient’s severity of SUD illness with treatment levels that run a continuum marked by five basic levels of care. The principles, concepts, and criteria of the ASAM Criteria promote good stewardship of resources in the addiction, mental health, and general health care systems.

Outpatient ASAM Level 1 Individual and group counseling up to 9 hours a week for adults Determined by a Medical Director or Licensed Practitioner of the Healing Arts (LPHA) Services can be provided in-person, by telephone or by telehealth (except group) Addition of family therapy

Intensive Outpatient ASAM Level 2.1 Minimum of nine hours with a maximum of 19 hours a week for adults Determined by a Medical Director or LPHA Services can be provided in-person, by telephone or by telehealth (except group) Addition of family therapy

Partial Hospitalization ASAM Level 2.5 20 or more hours of clinically intensive programming per week Providing this level of service is optional for participating counties

Residential 5 Levels of Residential Based on ASAM (Levels 3.1, 3.3, 3.5, 3.7 and 4.0) One level required for DMC-ODS No bed capacity limit The length of residential services range from 1 to 90 days with a 90-day maximum for adults

Residential Medical necessity can authorize a one-time extension of up to 30 days on an annual basis Only two non-continuous 90-day regimens will be authorized in a one-year period Perinatal clients may receive a longer length of stay based on medical necessity CDRH and Acute Free Standing Psych paid through the FFS system

Withdrawal Management (Levels 1, 2, 3.2, 3.7 and 4 in ASAM) Determined by a Medical Director or LPHA Monitored during detoxification IMD expenditure approval for Chemical Dependency Recovery Hospitals and Free Standing Psychiatric Hospitals (paid through FFS system)

Opioid (Narcotic) Treatment Program ASAM OTP Level 1 Required service in all opt-in counties Adding buprenorphine, disulfiram and naloxone in NTP settings Minimum fifty minutes of counseling sessions up to 200 minutes per calendar month or more with medical necessity

Recovery Services May access recovery services after completing the course of treatment, if triggered, if relapsed or as a preventative measure to prevent relapse Provided face-to-face, by telephone, or by telehealth with the beneficiary and may be provided anywhere in the community

Case Management Counties will coordinate case management services Services can be provided in various locations Coordinate with Mental and Physical Health Provided face-to-face, by telephone, or by telehealth

Criminal Justice System Additional Lengths of Stay (up to 6 months residential; 3 months Federal Financial Participation (FFP) with a one-time 30-day extension) If longer lengths, other county identified funds can be used

County Responsibilities Selective Provider Contracting Access to Services Medication Assisted Treatment Contracting Requirements Provider Appeals Process Residential Authorization

County Responsibilities County Implementation Plan County Fiscal Plan Two Evidence Based Practices (motivational interviewing, Cognitive-Behavioral Therapy, Relapse Prevention, Trauma-Informed Treatment, Psycho-Education)

County Implementation Plan Collaborative Process Treatment Services Client Flow Access Plan Description (Narrative)

County Responsibilities MOU with all managed care providers Comprehensive Screening Beneficiary Engagement Shared Plan Development/Treatment Planning Case Management Activities Dispute Resolution Care Coordination/Referral Tracking Navigation Support

County Responsibilities Beneficiary Access Number Care Coordination with Mental and Physical Health Services State/County Contract

State Responsibilities Integration Plan Innovation Accelerator Program ASAM Designation for Residential facilities Oversee Provider Appeals Process Monitoring Plan Timely Access Program Integrity Triennial Reviews

Quality Improvement Counties must have: QI Plan QI Committee Review Accessibility of Services Data Utilization Management Program Participate in Annual External Quality Reviews

Financing Rates Counties will negotiate provider rates by modality (except for NTP Services which will remain set by DHCS) The state will have final approval of the rates If the state rejects the rates, the county can resubmit revised rate

Financing Realignment Counties receive realignment funds derived from sales tax revenues deposited into their Behavioral Health Subaccount to pay for a portion of DMC treatment services 

Financing The cost of all DMC Waiver services will be shared among the federal government, State government and the counties The Federal government will continue to pay FFP for the existing population (mandatory) at the 50% rate (including residential services)

Financing The Federal government will pay FFP for the expansion population at the applicable enhanced rate (including residential), currently 100%, decreasing to 95% in 2017, and so on until reaching 90% in 2020 and beyond Sharing Ratio is county specific

DMC-ODS Waiver Implementation Regional Implementation Phase I – Bay Area (May-August 2015) Phase II – Southern California Phase III – Central Valley Phase IV – Northern California Phase V – Tribal Delivery System

DMC-ODS Waiver Implementation DHCS DMC-ODS Website http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx