1. Implementing Medicaid Behavioral Health Reform in New York
Redesign Medicaid in New York State
Implementing Medicaid Behavioral Health Reform in New York
NYSRA-NYSACRA Community Integration Leadership Institute: Advancing Outcomes
June 3, 2014

2. Agenda Overview of BH Transition to Managed Care BHO Phase 2 Status
Behavioral Health Managed Care Transition Timeline
RFQ Standards
Next Steps 2

3. BH Transition to Managed Care3

4. Medicaid Redesign Team: Objectives
Fundamental restructuring of the Medicaid program to achieve:
Measurable improvement in health outcomes
Sustainable cost control
More efficient administrative structure
Support better integration of care 4

5. Medicaid Redesign Team BH Recommendations
Behavioral Health will be managed by:
Qualified health Plans meeting rigorous standards (perhaps in partnership with a BHO)
All Plans MUST qualify to manage currently carved out behavioral health services and populations
Plans can meet State standards internally or contract with a BHO to meet State standards
Health and Recovery Plans (HARPs) for individuals with significant behavioral health needs
Plans may choose to apply to be a HARP with expanded benefits 5

6. Principles of BH Benefit Design
Person-Centered Care management
Integration of physical and behavioral health services
Recovery oriented services
Patient/Consumer Choice
Ensure adequate and comprehensive networks
Tie payment to outcomes
Track physical and behavioral health spending separately
Reinvest savings to improve services for BH populations
Address the unique needs of children, families & older adults 6

7. Qualified Plan vs. HARP Qualified Managed Care Plan
Health and Recovery Plan
Medicaid Eligible
Benefit includes Medicaid State Plan covered services
Organized as Benefit within MCO
Management coordinated with physical health benefit management
Performance metrics specific to BH
BH medical loss ratio
Specialized integrated product line for people with significant behavioral health needs
Eligible based on utilization or functional impairment
Enhanced benefit package - All current PLUS access to 1915i-like services
Specialized medical and social necessity/ utilization review for expanded recovery-oriented benefits
Benefit management built around higher need HARP patients
Enhanced care coordination - All in Health Homes
Performance metrics specific to higher need population and 1915i
Integrated medical loss ratio 7

8. Behavioral Health Benefit Package
Behavioral Health State Plan Services –Adults
Inpatient - SUD and MH
Clinic – SUD and MH
PROS
IPRT
ACT
CDT
Partial Hospitalization
CPEP
Opioid treatment
Outpatient chemical dependence rehabilitation
Rehabilitation supports for Community Residences (Not in the benefit package in year 1) 8

9. Menu of 1915i-like Home and Community Based Services - HARPs
Rehabilitation
Psychosocial Rehabilitation
Community Psychiatric Support and Treatment (CPST)
Habilitation
Crisis Intervention
Short-Term Crisis Respite
Intensive Crisis Intervention
Mobile Crisis Intervention
Educational Support Services
Support Services
Family Support and Training
Training and Counseling for Unpaid Caregivers
Non- Medical Transportation
Individual Employment Support Services
Prevocational
Transitional Employment Support
Intensive Supported Employment
On-going Supported Employment
Peer Supports
Self Directed Services 9

10. BHO Phase 2 Status 10

11. BHO Phase 2 Status Revised RFQ based on RFI comments
RFQ distributed (with draft NYC HARP rates) on March 21, 2014
OMH:
DOH: h_transition.htm
RFQ Applicant’s Conference held on May 2, 2014 in NYC
NYC Applications due June 6, 2014
Rest of State - approximately six months later 11

12. 12

13. RFQ Standards 13

14. RFQ Performance Standards
Organizational Capacity
Experience Requirements
Contract Personnel
Member Services
Network Service
Network Monitoring
Network Training
Utilization Management
Clinical Management
Cross System Collaboration
Quality Management
Reporting and Performance Management
Claims Processing
Information Systems and Website Capabilities
Financial Management
Performance Incentives
Implementation planning 14

15. Contract Personnel
HARPs must have full time dedicated BH Medical and Clinical Director
These positions may be shared if the HARP has fewer than 4,000 State identified HARP eligibles
Subject to certain restrictions, Plans may share positions and functions between Mainstream MCOs and HARPs
Plans must demonstrate to NYS that they or their managerial staff meet the experience requirements established in the RFQ
Plans must demonstrate that they have an adequate number of managerial and operational staff to meet the needs of their members. 15

16. Member Services
Requires Service Centers with several capabilities including:
Provider relations and contracting UM
BH care management
24/7 day capacity to provide information and referral on BH benefits
24/7 day capacity to respond to crisis calls 16

17. Utilization Management
Plans must use medical necessity criteria to determine appropriateness of ongoing and new services
Plans prior authorization and concurrent review protocols must comport with NYS Medicaid medical necessity standards
These protocols must be reviewed and approved by OASAS and OMH in consultation with DOH
Plans will rely on the LOCADTR tool for review of level of care for SUD programs as appropriate
HARP UM requirements must ensure person centered plan of care meets individual needs 17

18. Clinical Management
The RFQ establishes clinical requirements related to:
The management of care for people with complex, high-cost, co occurring BH and medical conditions
Promotion of evidence-based practices
Pharmacy management program for  BH drugs 
Integration of behavioral health management in primary care settings
Additional HARP requirements include oversight and monitoring of:
Health Home services and 1915(i) assessments
Access to 1915(i)-like services
Compliance with conflict free case management rules (federal requirement)
Compliance with HCBS assurances and sub-assurances (federal requirement) 18

19. Network Service Requirements
Plan’s network service area consists of the counties described in the Plan’s current Medicaid contract
There must be a sufficient number of providers in the network to assure accessibility to benefit package
Transitional requirements include:
Contracts with OMH or OASAS licensed or certified providers serving 5 or more members for a minimum of 24 months
Pay FFS government rates to OMH or OASAS licensed or certified providers for ambulatory services for 24 months
State will review proposed Plan/provider alternative payment arrangements requirements on a case by case basis 19

20. Network Service Requirements
Plans must contract with:
Opioid Treatment programs to ensure regional access and patient choice where possible
Health Homes
Plans must allow members to have a choice of at least 2 providers of each BH specialty service
Must provide sufficient capacity for their populations
Contract with crisis service providers for 24/7 coverage
Plans contracting with clinics with state integrated licenses must contract for full range of services available
HARP must have an adequate network of Home and Community Based Services

21. Network Service Requirements: State Operated
Plans must contract for State operated BH ambulatory services
Treated as “Essential Community Providers”
After 2 years, rates will need to be negotiated with Plans.
OMH and DOH will work with the MCOs to make the plans accountable financially and programmatically for
Continuing admissions to the State facilities
Transfers to the State facilities 21

22. Network Training
Plans will develop and implement a comprehensive BH provider training and support program
Topics include:
Billing, coding and documentation
Data interface
UM requirements
Evidence-based practices
HARPs train providers on HCBS requirements
Training coordinated through Regional Planning Consortiums (RPCs) when possible
RPCs are comprised of each LGU in a region, representatives of mental health and substance abuse service providers, child welfare system, peers, families, health home leads, and Medicaid MCOs
RPCs work closely with State agencies to guide behavioral health policy in the region, problem solve regional service delivery challenges, and recommend provider training topics
RPCs to be created 22

23. Claims Administration
The RFQ language allows Plans flexibility to pay for services using telemedicine consistent with Federal standards
The RFQ requires that Plans accept web-based claims
Plans must track and pay Health Homes to administer care coordination 23

24. Year One Performance Measures
Existing QARR and Health Home measures for physical and behavioral health for HARP and MCO product lines
BHO Phase 1 measures will continue to be run administratively
New measures being proposed for HARPs based on data collected from 1915(i) eligibility assessments
Member Satisfaction – all are existing QARR measures
Based on CAHPS survey
A recovery focused survey for HARP members is also being developed.  Measures derived from this survey may be created in the future 24

25. Financial Management
HARP rate does not include 1915(i) home and community based services
In the first year, HCBS paid on a non-risk basis
Plans will act as an Administrative Services Organization (ASO)
NYS will identify and designate 1915(i) providers
NYS will establish initial 1915(i) payment rates 25

26. Financial Management
State is modifying current psychiatric inpatient stop loss policy for Mainstream Plans and HARPs
Change to episodes of care - replaces stop loss based on cumulative days per person per year
Increases Plan financial responsibility for days of care over three years
Financial impact of psychiatric inpatient stop-loss proposal:
If no change, NYS would reimburse the MCOs about $240 million in psychiatric stop loss
With the change, by year 3 and after, Plan premiums increase by $210 million while the stop-loss pool is reduced to $30 million

27. Performance Incentives (under consideration)
Mainstream MCOs:
Bifurcate the mainstream QI award
Award a percentage of the existing performance pool (more than $200M) separately based on behavioral health measures
HARPs:
Year one: no withhold or quality incentive
Year two: up to a 1% withhold to pay a quality incentive
Year three: up to 1.5% withhold to pay a quality incentive
Year four and ongoing: up to 2.0% withhold to pay a quality incentive 27

28. Next Steps 28

29. Next Steps Ongoing Plan Engagement Plan/Health Home collaboration:
Identify care management roles and responsibilities beyond the existing Health Home/Plan agreement
Determine the care management model for HARP members and HARP eligibles that are not enrolled in Health Homes
Building Health Home capacity for HARP enrollees
Work with Plans and Health Home to collect and analyze Health Home performance
Risk Mitigation Mechanism
Work with Plans to develop a “Balanced Risk Corridor” and "Effective MLR of 90%"
Finalize performance incentive structure 29

30. Next Steps 1915i program development
Develop guidance for 1915i services
Designating 1915i qualified providers
Work with CMS to streamline assurances/sub-assurances
Finalize Year 2 performance measures
NYS will develop a Regulatory Reform Workgroup
Provide ongoing technical assistance for Plans and providers
Implement Start-Up Activities (with funding in Executive Budget)
Facilitate creation of Regional Planning Consortiums (RPCs) 30

31. OMH Next Steps Provide Technical Assistance Data Analysis
Regulatory Reform
Housing Supports
Integration of State Operations
Building OMH (Central and Field Office) capacity for
RPC coordination
Plan/ Provider liaison functions
Plan Oversight