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

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

3. 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

4. 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)

5. 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:

6. 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.

7. 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.

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

9. 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

10. 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

11. 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”.

12. 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

13. 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.

14. 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

15. 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.

16. 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

17. 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

18. 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

19. 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

20. 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: