Drug Medi-Cal Organized Delivery System Waiver Waiver Advisory Group Draft State/County Contract February 13, 2015.

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Presentation transcript:

Drug Medi-Cal Organized Delivery System Waiver Waiver Advisory Group Draft State/County Contract February 13, 2015

DMC Organized Delivery System Waiver Agenda: Overview of the Contract Changes to the contract for the Waiver Parking Lot for issues Next Steps

DMC Organized Delivery System Waiver Overview of Contract: THIS IS A “DRAFT” – DHCS is still working its way through all of the provisions and formatting of the contract. Contract components Exhibits A – E are State boilerplate and assurances and will not be reviewed Focus for today: Exhibit A, Attachment I

DMC Organized Delivery System Waiver CONTRACT COMPONENTS: Standard FY 14/15 State-County contract language – (black) 42 CFR 438 requirements - (Green) Mental Health Plan (MHP) boilerplate – (Blue) DMC-ODC Special Terms and Conditions (STC’s) – (Purple)

DMC Organized Delivery System Waiver CONTRACT COMPONENTS (Cont.): 42 CFR 438 Requirements: The Waiver is proposing an organized delivery system (ODS) for SUD services, and this falls under the classification of a managed care Prepaid Inpatient Health Plan (PIHP), therefore the Center for Medicare and Medicaid Services (CMS) requires the Waiver to use Part 438 of the Code of Federal Regulations (42 CFR 438) for managed care plans as the regulatory basis for the plan. CMS requires these provisions to ensure beneficiary protection and quality assurances. 438 requirements can be found at: http://cfr.regstoday.com/42cfr438.aspx

DMC Organized Delivery System Waiver CONTRACT COMPONENTS (Cont.): Mental Health Plan (MHP) Components: Why do we need to incorporate the MHP language into the Wavier contract? MHP language was incorporated into the Contract to leverage work already done by the Specialty Mental Health Services contract to meet the 438 requirements…lift and shift.

DMC Organized Delivery System Waiver CONTRACT COMPONENTS (Cont.): Special Terms and Conditions (STCs) The latest version of the STCs have been put into the contract. Not all STCs will be in the Contract if they overlap with the 438 requirements.

DMC Organized Delivery System Waiver Changes to the contract for the Waiver

DMC Organized Delivery System Waiver 1. Provision of Services No major changes; added 438 inclusion 1.A. Eligibility Added STC language regarding medical necessity based on DSM and ASAM Added 438 language regarding enrollment process 1.B. Covered Services Added 438 language regarding amount, duration and scope of services

DMC Organized Delivery System Waiver 1. Provision of Services (Cont.) 1.B.(d) Covered Services Added STC language regarding: Withdrawal management Additional Medication Assisted Treatment (MAT) Case Management Physician Management Non-Peri Residential SUD (excluding room and board) 1.C. Financing Added STC language for Rate Setting provisions

DMC Organized Delivery System Waiver 2. Availability and Accessibility of Service 2.A. Availability of Services Added language from the MHP to meet 438 requirements related to maintaining “adequate numbers and types of providers of medically necessary services” in the network. 2.B. Access to Services Added language from 438 regarding “second opinion…” Added STC language regarding counties shall have a toll free number for access. Added MHP language regarding “Timely access”.

DMC Organized Delivery System Waiver 2. Availability and Accessibility of Service (Cont.) 2.C. Adequate Capacity and Standards Added MHP language regarding network capacity. Demonstration of adequate capacity of services… …anticipated number of beneficiaries for the service area. …sufficient number, mix, and geographic distribution to meet needs… 2.D. Coordination and Continuity of Care Added 438 and MHP language Ensuring privacy of beneficiaries Ensuring beneficiary has ongoing source of primary care Beneficiaries with special care needs

DMC Organized Delivery System Waiver 2. Availability and Accessibility of Service (Cont.) 2.E. Authorization of Services Added MHP language regarding 2.F. Provision of Notice of Action Added 438 and MHP language regarding provisions for notifying beneficiaries of various actions, including authorization denials and other service denials. 2.G. Contents of a NOA Added 438 and MHP language to define what needs to be included in an NOA.

DMC Organized Delivery System Waiver 3. Provider Selection and Certification Added 438 and MHP language regarding various issues such as: Documented policies and procedures on how providers are credentialed. Discrimination of providers Declining of providers 3.A. DMC Certification and Enrollment Consistent with current contract requirements 3.B. Continued Certification

DMC Organized Delivery System Waiver 4. Recovery from Other Sources or Providers Added language from 438 and MHP Contractor shall recover the value of covered services whenever services are covered for the same service under State or federal programs. Contractor not claiming or collecting reimbursement from a beneficiary except for other health insurance coverage, share of cost, and co-payments.

DMC Organized Delivery System Waiver 6. Beneficiary Brochure and Provider List Added MHP language regarding Contractors responsibility for maintaining the production and updating of its brochures for beneficiaries rights. 9. Cultural Competence Plans Added MHP language 10. Implementation Plan

DMC Organized Delivery System Waiver 11. Additional Provisions Standard boilerplate contract language for compliance with various laws, Acts, Codes, etc. 12. Beneficiary Problem Resolution Processes Added language from MHP regarding appeals, grievances, and fair hearings. 13. Subcontracts Added 438 language to ensure proper subcontractor monitoring and oversight. 14. Program Integrity Added MHP language

DMC Organized Delivery System Waiver 17. Additional Requirements Added 438 and MHP language 18. Quality Management Program Need to review further… Evaluation Added STC language regarding UCLA’s role in conducting an evaluation of the Waiver 19. Quality Improvement Program

DMC Organized Delivery System Waiver 20. Utilization Management Program Need to review further… Added 438 and STC language 21. Practice Guidelines Added 438 and MHP language 22. Non-Drug Medi-Cal/SAPT Consistent with the current contract. 23. Definitions Added definitions for STC, MHP, and 438

DMC Organized Delivery System Waiver Next Steps: DHCS will continue to refine the Contract. Review Parking Lot Issues Questions/comments regarding the Contract may be submitted to: MHSUDStakeholderInput@dhcs.ca.gov