Benefit Plan Streamlining Spencer Clark, Patsy Coleman, Starleen Scott Robbins, DeDe Severino, Thelma Hayter 6/17/14 & 6/19/14 DMHDDSAS

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Benefit Plan Streamlining Purpose: To reduce LME-MCO administrative resources necessary to appropriately pull down DMHDDSAS Federal and State Single Stream funding. 2

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Benefit Plan Streamlining Summary Benefits: Reduces number of Benefit Plans significantly (from 35 to 10). Does not restrict eligibility for State/Federal services. Utilizes a subset of current Benefit Plans, to reduce the number of Benefit Plan changes necessary (<10% of clients). 3

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Benefits, Cont. Utilizes DSM-5 diagnostic criteria, ICD-9 diagnosis codes. Allows LME-MCOs flexibility in processing for ensuring eligibility for Benefit Plan and Services. Allows (but does not require) LME-MCOs to automate aspects of eligibility determination for some Benefit Plans. 4

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Benefits, Cont. Allows for extended end dates for Benefit Plan eligibility (reducing potential for denials due to expiration of eligibility), as long as continued eligibility is ensured through business processes such as authorization. Allows for concurrency between most Benefit Plans. 5

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Benefits, Cont. Should reduce the volume of denials due to eligibility issues. 6

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N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES New Policy The LME-MCO authorization and claims adjudication process must ensure that consumers who receive State/Federal funded services meet the eligibility criteria of the Service Definition or the Benefit Plan, whichever is strictest. The LME-MCO must maintain documentation to support this determination, and make it available to the Division or its agents upon request. 8

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Examples Consumer has been previously placed in AMI Benefit Plan, and provider is requesting authorization for outpatient treatment: –AMI Benefit Plan criteria is strictest, so as long as the individual meets those criteria (diagnoses and functioning) then LME-MCO may choose to authorize Same consumer, and provider is requesting ACTT: –ACTT entrance criteria are strictest and so must be met 9

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES LME-MCO Actions Necessary 1.Develop and/or revise business processes to ensure individuals are eligible for services through UM and claims processing. 2.Train UM staff on revised Benefit Plan Eligibility Criteria, Benefit Plan Diagnosis Array, and Service Array. 3.Ensure providers are utilizing DSM5 by August 1, 2014 and understand the Benefit Plan eligibility criteria. 10

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES LME-MCO Actions, Cont. 4.Identify any consumers with Benefit Plans that are being ended. For those who are not also in a continuing Benefit Plan, submit 834s to revise their eligibility, prior to submitting their first claim after July 31 st, (NCTRACKS R2W: BR12008-R0010 or 11) 5.Consider whether to extend the end date on Benefit Plan eligibility for consumers who are unlikely to lose eligibility. With procedures in place to support the new policy: Individual with I/DD could have an ADSN ending date of 2099 Child with CMSED could have a benefit plan end the day before 18 th birthday 11

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES LME-MCO Actions, Cont. 6.In NCTRACKS, add the GAP Benefit Plan to Providers who are contracted to perform initial assessments. 12

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Benefit Plans Semi-Automated Benefit Plan Determination: Benefit Plan eligibility may be determined through a semi- automated process for five Benefit Plans: –AMI, CMSED, ASTER, CSSAD and GAP. –The automated portion of the process should be based on the consumer’s age at the time of service and their primary diagnosis, where primary diagnosis is the main focus of attention or treatment. 13

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Benefit Plans Individual Benefit Plan Determinations: The remaining Benefit Plans: –ASWOM, ASCDR, ADSN, CDSN, and AMVET must continue to be determined individually, as they require review of several individual and clinical characteristics beyond the primary diagnosis and age group. 14

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Benefit Plans GAP = Generic Assessment Payment Effective 7/1/14 Collapses the 6 Age/Disability-specific “Assessment Only” Benefit Plans into one Intended to provide reimbursement for individuals who need assessment but end up ineligible for any other Benefit Plan (no concurrency allowed) Covers up to two assessments per year Eligibility is limited to 60 days 15

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES AMI Benefit Plan Revision Add to the list of Level of Functioning or Risk Factors: OR i. Any individual with chronic mental illness who is currently stable but without continued treatment and supports would likely experience significant decompensation and deterioration of functioning. 16

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Implementation The Benefit Plans that are expiring will be end- dated effective July 31, 2014 dates of service. Any consumers actively receiving services who are in these Benefit Plans only (and not in one of the remaining plans) will need to be switched to one of the remaining plans by this date. This is consistent with the August 1, 2014 implementation date for the DSM-5. 17

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Implementation has 2 Stages: 1.Inclusion in DMHDDSAS Benefit Plans after July 31, 2014 shall be based on the covered DSM-5 diagnoses and eligibility criteria listed in the Diagnosis Array and Eligibility Criteria documents. 2.ICD-9 diagnosis codes covered in FY14 (see the last tab in the attached Diagnosis Array workbook) will continue to be allowed for claims adjudication in NCTRACKS through the end of FY15, for the Benefit Plans that are not expiring. 18

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES FY14 Diagnosis Array 19

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES FY15 Diagnosis Array 20

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Benefit Plan Eligibility Criteria example 21

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Service Array 22

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Concurrency Table 23

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES FY15 Hierarchy 24

N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Next How to use the Diagnosis Array workbook Q&A Policy questions regarding these changes should be directed to Spencer Clark at Technical questions should be ed to 25