Methadone and Managed Care KDADS/BHS Presentation March 2015

Continuum of Services in Kansas All services are all based on clinical need/medical necessity and providers must obtain authorization to provide the services. Assessment Outpatient Intensive outpatient Reintegration Social detox Intermediate Overnight boarding for children in residential services at the designated women’s programs Sub-acute detox Peer Support Services There are 267 licensed SUD treatment providers across the state. Of these 267, forty three providers, with a total of 103 locations statewide, are designated to provide BHS funded treatment services. These providers offer a range of funded services including assessment, outpatient, intensive outpatient, reintegration, social detox, and intermediate. Licensed programs must have Licensed Addiction Counselors provide the services per Statute. Medicaid funded providers are able to offer and bill for Medicaid case management. These services are all based on clinical need/medical necessity and providers must obtain authorization to provide the services. All are publically funded by the BG, MCD, or both. March 2015

Methadone clinics in Kansas KDADS/BHS licenses 9 methadone clinics throughout the State. Only one receives public funds. Clinics have the capacity to serve a total of 2850 clients. The one publically funded clinic has the capacity to serve 600 each day. November 11, 2018

Drug of Choice This data comes from the KCPC which all publically funded programs must use. As you can see there are 816 clients that have other opiates as their drug of choice, and 192 that list Heroin as their drug of choice. These are statewide numbers. Only one of the clinics is included in this data. This is 400 over the number of clients the funded program has the capacity to serve. March 2015

History 1995- Integrated data system implemented Kansas Client Placement Criteria (KCPC) and ASAM criteria Fee for Service Required to target Federal Priority Populations KCPC was updated later to include the ASAM II criteria but has not historically included the ASAM criteria for MAT Paid for a daily unit of service $7.50, program allowed to charge a co-pay March 2015

History Continued 2007 Issues with Medicaid Applied for a 1915b waiver to ensure residential treatment was paid for Behavioral Health Services-Carve out Prepaid Inpatient Health Plan (PIHP) contract Oversees/Manages both Block Grant and Medicaid funds Clinic now approved to bill for Medicaid Methadone is not included in the Medicaid formulary for Addiction Treatment. Program initially allowed to continue to bill for units of service for block grant. Transitioned to requiring them to bill for outpatient individual and group and intensive outpatient treatment so MCO could approve or decline based on medical necessity. November 11, 2018

Current 2013 KanCare implemented Behavioral Health Services now Carved in Three Managed Care Contractors-Statewide Block Grant funding stays with non-Medicaid contractor So now we have a total of 4 entities that all of our publically funded programs must use. November 11, 2018

Performance/Quality Data Integrity-by looking at claims data and documentation BG monitoring CAP plan Quarterly census and other data collected Block Grant: VO pays for methadone maintenance via T1015 procedure code • FY 2013 – 5,029 units of methadone maintenance was received by 49 unique members (71.4% female) • FY 2014 – 4,614 units of methadone maintenance treatment was received by 41 unique members (58.5% female) o 7 members received T1015 methadone maintenance therapy during both fiscal years (65.1% female) o Clinical does not do any UM, looking at KCPCs or monitoring diagnoses. VO has only paid Block Grant claims. Quarterly census-look at trends, discuss at the quarterly director’s meeting November 11, 2018

Issues ASAM criteria not in the current KCPC MCOs and their Medical Directors lack of knowledge regarding MAT Private Pay clinics lacks the understanding of providing medical necessity Other clinics unwilling to provide funded services despite the higher rate for counseling KCPC does not currently include the new ASAM criteria Services for maintenance clients may be denied if they don’t fit into the criteria for IOP and OP services Documentation is not always “clinical enough” especially for long term clients Private pay providers don’t want to use our tool. Would like to do a data extract only. Not sure we can do that with the system we have. Don’t want to jump through government hoops so they remain publically funded. The clinics provide data that shows 46% of all the methadone clients make under $35,000 a year and that 48% all have a high school diploma or less. This indicates a possible need for public funding. All but one are privately funded (the one that is publically funded is actually a privately funded company. The one publically funded is KU Hospital. They do not want this track of funding to interfere with other funding streams they receive. March 2015

Solutions Conversion to a new data system in process, will include new ASAM criteria for opiate addiction Provide training to all MCO staff and Treatment providers requiring the use of the ASAM MAT criteria Work with non-funded clinics to become MCD providers. The conversion will include the new ASAM and clinical criteria for MAT March 2015

Questions March 2015