1 Drug Medi-Cal Organized Delivery System Waiver Presented by Karen Baylor, PhD, Deputy Director, MH/SU Division, DHCS and Patricia Ryan, MPA Consultant, CBHDA

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 2

ACA Expansion Increased Eligible Beneficiaries (Expanded Population) CA chose to expand modalities –IOT (for Mandatory and Expanded Populations) –Residential (for Mandatory and Expanded Populations) 3

ACA Expansion Residential Services Residential needed in the continuum of care Restricted due to the federal Medicaid Institutions for Mental Disease (IMD) exclusion Ninety percent of California’s residential bed capacity is considered an IMD Medicaid payment is not allowed for any services provided to Medi-Cal clients in IMDs Without the DMC-ODS Waiver Pilot, California cannot provide residential services 4

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 5

DMC Organized Delivery System Waiver Reduce emergency rooms and hospital inpatient visits Ensure access to SUD services Increase program oversight and integrity Place client in the least restrictive level of care 6

Stakeholder Process DHCS held Nine Waiver Advisory Groups Participants: counties, provider associations, Alcohol and Other Drug counselor certifying organizations, managed care health plans, public interest advocates, and legislature Meeting notes posted on the website 7

DMC ServicesSPA ( Non- Waiver Opt-in Waiver Outpatient/Intensive Outpatient XX NTPXX ResidentialX (one level) Withdrawal ManagementX (one level) Recovery ServicesX Case ManagementX Physician ConsultationX Additional MATX (optional) 8

General Provisions Amendment to Bridge to Reform and folded into Medi-Cal Waiver Pilot for 5.5 years Counties choose whether to opt-in 53 of 58 counties expressed an interest ASAM Criteria 9

Early Intervention Services SBIRT (screening, brief intervention and referral to treatment) American Society of Addiction Medicine (ASAM) Level 0.5 Provided by non-DMC providers to beneficiaries at risk of SUD (through FFS system) Referrals by managed care providers or plans to DMC-ODS will be governed by the Memorandum of Understanding 10

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 11

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 12

Partial Hospitalization ASAM Level or more hours of clinically intensive programming per week Providing this level of service is optional for participating counties 13

Residential 5 Levels of Residential Based on ASAM (Levels 3.1, 3.3, 3.5, 3.7 and 4.0) No bed capacity limit Services range from 1 to 90 days CDRH and Acute Free Standing Psych paid through the FFS system 14

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) 15

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 16

Additional Medication Assisted Treatment The goal of the DMC-ODS for Medication Assisted Treatment (MAT) is to open up options for patients to receive MAT by requiring MAT services in all opt-in counties, educate counties on the various options pertaining to MAT and provide counties with technical assistance to implement any new services. 17

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 18

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 19

Physician Consultation Services Designed to assist DMC physicians with treatment plans for DMC-ODS beneficiaries Medication selection, dosing, side effect management, adherence, drug-to-drug interactions, or level of care considerations 20

Criminal Justice System More parolees and probationers eligible for Medi- Cal with ACA expansion Many parolees and probationers have unmet SU needs If longer lengths of treatment are needed, other county identified funds can be used DHCS collaborating with CDCR’s Integrated Care Committee to redesign treatment services for parolees 21

County Responsibilities Assure Beneficiary Access to Culturally Competent Services Medication Assisted Treatment State-County Contract Requirements Provider Appeals Process Authorization of Residential Services Coordination with DMC-ODS Providers 22

County Responsibilities Selective Provider Contracting: Must maintain client access to services Must provide a continuum of care with the required services Must have policies & procedures for selection, retention, credentialing and re- credentialing Must ensure services are culturally competent

County Responsibilities County Implementation Plan Two Evidence-Based Practices Beneficiary Access Number Care Coordination with Mental and Physical Health Services (Integrated Care) State/County Contract Residential Authorization 24

County Responsibilities County Implementation Plan County implementation plans must ensure that providers are appropriately certified for the services contracted, implementing at least two evidence-based practices, trained in ASAM Criteria, and participating in efforts to promote culturally competent service delivery.

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 26

Quality Improvement Counties must have: QI Plan QI Committee Review Accessibility of Services Data Utilization Management Program Participate in Annual External Quality Reviews 27

State Responsibilities Provider Certification Approve Integration Plan Innovation Accelerator Program Approve ASAM Designation for Residential Facilities Oversee Provider Appeals Process Monitoring Plan 28

New Opportunities Many new Med-Cal enrollees under ACA expansion have SUD needs, including criminal justice population Under “Public Safety” state-county realignment, county incentives to address unmet needs are increasingly aligned DMC-ODS gives state/counties the tools to work with primary care/mental health to deliver integrated/coordinated services in a culturally competent, recovery-oriented way New tools to work toward “triple aim” goal of ACA 29

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CMS SMD # CMS issued a guidance letter July 27, 2015 to inform states of opportunities to design service delivery systems for individuals with SUD. California is the first state to receive approval under this guidance. 31

Evaluation University of California, Los Angeles, (UCLA) Integrated Substance Abuse Programs will conduct the evaluation Four key areas of access, quality, cost, and integration and coordination of care 32

Federal 438 Requirements Counties held to all federal 42 CFR 438 requirements (quality assurance, beneficiary protections, access) External Quality Review requirements must be phased in within 12 months of having an approved implementation plan 33

Tribal Delivery System DHCS will consult with the tribes and the four tribal 638/urban programs after approval of the amendment Phase 5 implementation will focus on the tribal system after the amendment has been approved by CMS 34

Phase I – Bay Area Phase II – Southern California Phase III – Central Valley Phase IV – Northern California Phase V – Tribal Delivery System 35 Regional Implementation

Technical Assistance from DHCS State Implementation Plan Designing a Training Plan DHCS Substance Use Disorders Statewide Conference “Organizing the SUD Delivery System” October 26-27, DMC-ODS Waiver Implementation

Final Thoughts All eyes are on California, so let’s make sure we do this right! 37

DHCS DMC-ODS Website /Drug-Medi-Cal-Organized-Delivery- System.aspxhttp:// /Drug-Medi-Cal-Organized-Delivery- System.aspx 38 DMC-ODS Waiver Implementation