1. Medicaid System Change June 10, 2015

2. 2 The Forces of Change  Medicaid Redesign Process  Managed Care  Health and Recovery Plans (HARPs)  Health Homes  Balanced Incentive Program (BIP)  Home and Community Based Services (HCBS)  Delivery System Reform Incentive Payments (DSRIP)  Performing Provider Systems (PPS)  Value Based Payments (VBP)

3. 3 Managed Care

4. 4 Managed Care Goals Fundamental restructuring of the Medicaid program to achieve:  Measurable improvement in health outcomes  Sustainable cost control  Support better integration of care  Reduce unnecessary Inpatient and Emergency services  Expand access to Community Support Services  Care Management  System accountability

5. 5 NYS Managed Care  Currently all Medicaid aid categories are enrolled in managed care for physical health and pharmacy  Limited mental health benefit for TANF and SNF  SSI behavioral health fully carved out  Individuals dually eligible for Medicaid and Medicare are excluded  All BH services will now be included in managed care  NYC 10/1/15  ROS 7/1/16

6. 6 HARP  Target Population – Medicaid eligible adults 21 and over with a serious behavioral health diagnosis and minimal behavioral service utilization  Approximately 140,000 individuals statewide  60,000 in NYC  80,000 ROS  Passive enrollment process  Individuals eligible for both Medicaid and Medicare are excluded from participation

7. 7 Behavioral Health Benefit Package  Behavioral Health State Plan Services –Adults  Inpatient - SUD and MH  Clinic – SUD and MH  Personalized Recovery Oriented Services (PROS)  Intensive Psychiatric Rehabilitation Treatment (IPRT)  Assertive Community Treatment (ACT)  Continuing Day Treatment (CDT)  Partial Hospitalization  Comprehensive Psychiatric Emergency Program (CPEP)  Outpatient chemical dependence rehabilitation  Opioid treatment

8. 8 HCBS Services for HARP Access based on functional/clinical assessment for targeted populations Rehabilitation Psychosocial Rehabilitation Community Psychiatric Support and Treatment (CPST) Habilitation Crisis Intervention Short-Term Crisis Respite Intensive Crisis Respite Educational Support Services Peer Supports Self Directed Services Support Services Family Support and Training Non-Medical Transportation Individual Employment Support Services Prevocational Transitional Employment Intensive Supported Employment On-going Supported Employment

9. 9 Health Homes and Behavioral Transition to Managed Care  All HARP members will be offered Health Home care management services  The Community Mental Health (CMH) suite of the InterRAI has been customized for NYS and includes:  Brief Assessment to determine HCBS eligibility  Full Assessment to identify needs and assist in the development of a care plan including HCBS  Health Homes will conduct the InterRAI assessments  Health Homes will develop person-centered care that integrate physical and behavioral health service and include HCBS services

10. 10 NYS Priorities During Rollout To ensure:  Appropriate shift of services from inpatient to community-based  Increased use of recovery oriented services  Financial stability of providers and system  Timely access to Home and Community Based Services  Adoption of integrated care models To avoid:  Dramatic reductions in inpatient LOS without corresponding increase in outpatient services  Disruption of service delivery system  Cost-shifting to other systems

11. 11 Information Providers Require  Numbers/Percentage served who will be enrolled in  HARP  Mainstream MC  Duals  Other MC Products (FIDA)  The Managed Care plan individuals are enrolled in  How many Plans/Contracts  Existing contract/ New contracts  Contract Terms  Billing Requirements and Payment terms

12. 12 Information Providers Require  The Cost of each Service and its Margin  Volume  Breakeven point  State Plan or HCBS  Data on the population served  Program LOS  Average  Median  Outcomes  Achievement of Goals  Discharge Data  Cost per episode of care

13. 13 DSRIP

14. 14 The DSRIP Challenge: Transforming the Delivery System DSRIP is a major effort to transform the NYS Medicaid Healthcare Delivery System  $8 billion Federal funding to transform from a fragmented and overly focused on inpatient care towards integrated and community, outpatient focused  Specific performance metrics over five years demonstrating significant system change

15. 15 The DSRIP Challenge: Value Based Purchasing The transformation of the delivery system can only become and remain successful when the payment system is transformed as well Many of our system’s problems are rooted in how services are paid for  Paying providers Fee For Service incentivizes volume over value, pays for inputs rather than outcome; an avoidable readmission is financially rewarded more than a successful discharge  Our current payment system does not adequately incentivize prevention, coordination or integration

16. 16 Value Based Purchasing Value over Volume  FFS  More Services = More Dollars  Outcomes may bear no relationship to the number of services provided  Easily engaged over hard to reach  Over the next 5 Years 90% of Managed Care Contracting must use alternative payment mechanisms  Sub-capitation  Case payments  Performance Based