1. CCBHC Prospective Payment System (PPS) Technical Assistance Session 9 Webinar: Managed Care Payments April 21, 2016 2:30-4:00 pm ET

2. I.Welcome II.Managed Care Payments a.Webinar Goal b.Options for Delivery of Services c.Actuarial Certifications d.Wrap Around Payments e.Contract Considerations III.Questions IV.PPS Webinar Schedule Webinar Agenda 2

3. The purpose of this webinar is to further explain how states can integrate demonstration services into a Managed Care delivery system. Webinar Goal 3

4. Ground Rules for Demonstration when using Managed Care 4 All Medicaid beneficiaries must have access to CCBHC demonstration services, regardless of delivery system CCBHCs must get paid the PPS determined by the state or its actuarial equivalent – If using the actuarial equivalent, states must first develop PPS to determine if alternate payment is equivalent

5. State Options for Integration of Demonstration Serves Under the demonstration states can choose how they wish to provide demonstration services for those enrolled in a managed care delivery system: Provide demonstration services through Fee For Services (FFS) or carve out from managed care. Provide demonstration services by one Managed Care Entity (MCE) o Managed Care Organization (MCO), o Prepaid Inpatient Health Plan (PIHP), or o Prepaid Ambulatory Health Plan (PAHP). Provide demonstration services through multiple MCEs. 5

6. Services Provided through FFS Considerations: o Notify MCE enrollees on how to access demonstration services through CCBHCs. o Ensure CCBHCs are informed on how to bill the state. o Ensure MCEs know they are not to pay CCBHCs for demonstration services. o Ensure individuals served by CCBHCs are informed on how to file grievance or complaints. 6

7. Services Provided Through a Single MCE Considerations: Network adequacy requirements for CCBHCs Ensure MCEs know how to identify CCBHC providers and individuals utilizing CCBHCs in their internal systems. Ensure MCEs know what services are covered under the demonstration in order to code the claims properly. Ensure MCEs know what amount they are to pay to CCBHCs o Full PPS Rate or Wraparound Payment Methodology Ensure individuals served by CCBHCs are informed on how to file grievance or complaints. Ensure CCBHCs are informed on claims billing/claims resolutions processes for each MCE. 7

8. Services Provided by Multiple MCEs States may have contracts with other entities such as PIHPs or PAHPs that specialize in behavioral health services and allow for Medicaid enrollees to potentially be enrolled with multiple entities at the same time. Because of this, clinics may not be aware which entity is responsible for payment of the behavioral health services. States are required to clearly define how it will ensure that duplication of services or payments will not occur. 8

9. Actuarial Certification Certifications are not required for PPS development, however a revised certification is required for any change in capitation payments or services covered. Certifications must clearly document what services are carved out (FFS) and what services are included in managed care. How to account for duplicate services To ensure proper enhanced FMAP claiming, states will need to revise their actuarial certification letters to show how much of the capitation payment is associated with the CCBHC services. 9

10. Full PPS paid by MCEs PPS payments can be fully incorporated into the managed care capitation rate and managed care plans will be required to pay CCBHCs the actual PPS rate or its actuarial equivalent. Recommended only when CCBHCs are paid by one MCE. Capitation rates should consider how the inclusion of CCBHC payments may impact other services covered by the MCE paying for the CCBHC as well as any other MCE in the delivery system. 10

11. Wrap Around Payment Methodology This option incorporates a reconciliation process using wraparound supplemental payments to ensure the total payment made to the CCBHCs is equivalent to the PPS rate. MCEs will typically pay a market rate for the distinct service provided. If it is found that the managed care payments were less than the required PPS amount through the reconciliation process, states are required to make additional payments to the clinics to make up for the shortfall. This shortfall can either be paid directly to the CCBHC by the state or by the MCOs as a pass-through. Statutory requirements do not dictate the frequency of the wraparound payments, but it is recommended that payments to the CCBHCs are made quarterly and reconciled annually. 11

12. Contract Considerations The state’s contract with Managed Care Entities must contain the following: Description of covered services Data collection and reporting requirements to ensure accuracy and to measure performance. It is recommended the state include items such as: o Definition of the data to be reported o Data collection period o Reporting requirements methodology o Entity responsible for data collection 12

13. Questions 13

14. Webinar Topic Date Medicaid State Plan SustainabilityThu 5/19, 2:30-4pm ET Open TA SessionThu 6/16, 2:30-4pm ET PPS Webinar Topics & Schedule *Topics and dates are subject to change 14

15. Mailboxes – CMS mailbox for PPS guidance-related questions: CCBHC-Demonstration@cms.hhs.gov CCBHC-Demonstration@cms.hhs.gov – CMS mailbox for Quality Based Payment-related questions: MACQualityTA@cms.hhs.gov MACQualityTA@cms.hhs.gov 223 PPS TA SharePoint Site Link – Crosswalk template for State developed cost reports Q&As posted at the 223 Landing Page on Medicaid.gov 223 Landing Page on Medicaid.gov Collaboration Tools 15