1. Commonwealth of Massachusetts Executive Office of Health and Human Services Chapter 257 of the Acts of 2008 Provider Information and Dialogue Session: Ambulatory Services May 28, 2013 www.mass.gov/hhs/chapter257 eohhspospolicyoffice@state.ma.us

2. 2 Agenda Chapter 257 of the Acts of 2008 Overview Definition and Overview of Programs Procurement Approach Review of Pricing Analysis and Methodologies Components Under Ambulatory Services Current Rate Set Components Current Department Set Components Proposed Components Model Budget Timeline and Key Milestones

3. 3 Chapter 257 of the Acts of 2008 Regulates Pricing for the POS System Chapter 257 places authority for determination of Purchase of Service reimbursement rates with the Secretary Of Health and Human Services under MGL 118G. The Center for Health Information and Analysis provides staffing and support for the development of Chapter 257 pricing. Chapter 257 requires that the following criteria be considered when setting and reviewing human service reimbursement rates: Reasonable costs incurred by efficiently and economically operated providers Reasonable costs to providers of any existing or new governmental mandate Changes in costs associated with the delivery of services (e.g. inflation) Substantial geographical differences in the costs of service delivery Rates that have undergone Chapter 257 rate setting processes are subject to regular review. Rate reviews will reflect: Changes to the service since the preceding review Any systemic or programmatic changes desired by purchasing agencies Any updated or new data brought forth to support rate adjustments

4. 4 The Cost Analysis and Rate Setting Effort has Several Objectives and Challenges Objectives and Benefits Development of uniform analysis for standard pricing of common services Rate setting under Chapter 257 will enable: A.Predictable, reimbursement models that reduce unexplainable variation in rates among comparable, economically operated providers B.Incorporation of inflation adjusted prospective pricing methodologies C.Standard and regulated approach to assessing the impact of new service requirements into reimbursement rates Transition from “cost reimbursement/maximum obligation” to “unit rate” Challenges Ambitious implementation timeline Data availability and integrity (complete/correct) Constrained financial resources for implementation, especially where pricing analysis warrants overall increases in reimbursement rates Cross system collaboration and communication Coordination of procurement with rate development activities Pricing Analysis, Rate Development, Approval, and Hearing Process Data Sources Identified, Components Reviewed, Model Budgets Developed Provider Consultation Review/ Approval: Departments, Secretariat, and Admin & Finance Public Comment and Hearing Possible Revision / Promulgation

5. 5 Agenda Chapter 257 of the Acts of 2008 Overview Definition and Overview of Programs Procurement Approach Review of Pricing Analysis and Methodologies Components Under Ambulatory Services Current Rate Set Components Current Department Set Components Proposed Components Model Budget Timeline and Key Milestones

6. 6 AMBULATORY SERVICES Service Class: Clinical, Medical Counseling, Therapy and Treatment Activity Code: 3385 Ambulatory Services and 3315 Driver Alcohol Education Total Spend in FY12: Over $1.7 million Mass Health purchases some of the same units. Mass Health total spend in FY12: $800K Procurement: Once rates are promulgated, DPH will issue a procurement for Ambulatory Services. Contracts awarded will be Master Agreement. Procurement will be rolling enrollment and new bidders can apply during the life of the procurement. Proposals will be reviewed on a periodic basis. Gambling Services will be procured at the same time as Ambulatory Services

7. 7 Agenda Chapter 257 of the Acts of 2008 Overview Definition and Overview of Programs Procurement Approach Review of Pricing Analysis and Methodologies Components Under Ambulatory Services Current Rate Set Components Current Department Set Components Proposed Components Model Budgets Timeline and Key Milestones

8. 8 Ambulatory Services: Components Current Components Purchased Rates are regulated under 101 CMR 346.00 Rates for Certain Substance Abuse Programs: –Current rates cover: Counseling (Individual, Family and Group), Case Consultation, Assessment, Day Treatment and Driver Alcohol Education –DPH negotiated rates: Psycho Educational Groups and Acupuncture Consideration for Future Purchase: Evidence based support services for clients in recovery. Substance Abuse Clinical Case Management –In Home Therapy –Recovery Coaching –Telephone Recovery Support

9. 9 Ambulatory Services: Current Components ServiceDPH PurchaseMass Health Direct Purchase Counseling* Individual Family Group Case Consultation Assessment Day Treatment* DAE Assessment Individual Group DPH Rate* Psycho Ed Acupuncture *Includes Gambling Services XXXXXXXXXXXXXXXXXXXX XXXXXXXXXX

10. 10 Possible New Components Substance Abuse Clinical Case Management: Definition Individualized case management as part of a clinical outpatient service Two levels: Master’s Level and Non-Master’s Level Master’s Level includes evidence-based models that integrate clinical treatment and case management services such as CRAFT (Community Reinforcement and Family Training) or CRA (Community Reinforcement Approach). Non-Master’s Level requires at least 2 years experience in the recovery field and preferred LADC or CADAC or recovery coach certification, supervised by a Master’s Level clinician. Directed toward high risk and vulnerable populations such as -pregnant women -parents with DCF involvement -higher utilizers of detoxification -intravenous drug users -homeless persons -transitional aged youth -consumers involved with the criminal justice system Links to community resources such as housing, employment, education, health care and facilitates access to mainstream benefits. Facilitates, coordinates and supports ongoing engagement in community-based treatment and recovery services. Provides education on addiction, co-occurring disorders, recovery and rehabilitation

11. 11 Possible New Components In Home Therapy: Definition: Individual or family therapy session that is provided in the home. The following criteria must be met: Based on a clinical assessment which identifies barriers to client receiving services at the clinic site. Must be provided by Master’s level clinician who is supervised by a Senior Clinician at the clinic site. Continuing need for In-Home Therapy must be evaluated every 90 days. Cost of clinician time and travel is included in the rate and is billable up to 8 units per day in 15 minute units. Recovery Coaching Definition: Non-clinical service provided by an individual who has been certified as a Recovery Coach. A formal degree is not required. Recovery Coach (RC) serves as a recovery guide or role model in the management of recovery and assists the recoveree to identify and overcome barriers to recovery. RCs connects recoverees with recovery support services and encourages hope, optimism and health RCs provide non-judgmental advocacy and help recoverees problem solve and meet their recovery goals. RCs are supervised by a staff person who is also trained and certified as a RC and has a greater length of experience than the supervisee as a RC.

12. 12 Possible New Components Telephone Recovery Support Definition: Uses an evidenced based model which offers training on how to provide telephonic support Non-clinical services provided by a person who has completed the training in the model that is being used Offers the recoveree regular phone calls for a period of time to aid in recovery support

13. 13 Model Budget based on Salaried Clinical Staff Model Budget based on a Salaried not a Fee-For Service Staffing Pattern BSAS highly emphasizes that clinical staff be supported through regular supervision, training, and other administrative supports. BSAS will monitor for clinical supervision and training. BSAS will monitor for licensing standards being met in clinical records and all documentation.

14. 14 Ambulatory Services: Outpatient Counseling Notes: ● Productivity standard was calculated by taking standard 2080 yearly fiscal hours of work per employee and backing out non -direct service hours made up of: vacation, sick & personal time, holidays, training, travel time, supervision and administrative (paperwork). ● Direct care staff were identified as the primary staff and were set at 1.00 FTE. All other FTEs were set in relation to direct care staffing. Clinical and Support staffing were set by purchasers. ● Tax and fringe was set at the measure of central tendency for a combined outpatient and methadone counseling FY11 UFR sample. ● Analysis of FY11 UFR data informed the administrative allocation percentage. ● CAF assumes a third quarter 2013 effective date and goes to the prospective date of second quarter of 2015, using the Spring 2013 Massachusetts Economic Indicators from IHS Global Insight. ● Rate will also be used as the foundation for Assessment, Case Consultation, Driver Alcohol Education and Group Counseling rates. ● The Group Counseling rate will assume two hours of staff time for an hour and a half group session for five individuals.

15. 15 Ambulatory Services: Clinical Case Management Non-Master’s Level Notes: ● Productivity standard was calculated by taking standard 2080 yearly fiscal hours of work per employee and backing out non -direct service hours made up of: vacation, sick & personal time, holidays, training, supervision, 5 hrs/week travel time, and 3 hours/week administrative (paperwork). ● Direct care non-master’s staff were identified as the primary staff and were set at 1.00 FTE. All other FTEs were taken from the outpatient counseling model except support staffing which was set at half the amount of outpatient counseling. ● Tax and fringe, administrative allocation and the cost adjustment factor are consistent with other outpatient services models..

16. 16 Ambulatory Services: Clinical Case Management Master’s Level Notes: ● Productivity standard was calculated by taking standard 2080 yearly fiscal hours of work per employee and backing out non -direct service hours made up of: vacation, sick & personal time, holidays, training, supervision, 5 hrs/week travel time, and 3 hours/week administrative (paperwork). ● Direct Care Master’s staff were identified as the primary staff and were set at 1.00 FTE. All other FTEs were set in relation to Direct Care Master’s staffing. ● Tax and fringe, administrative allocation and the cost adjustment factor are consistent with other outpatient services models. ● This rate will also be used as the foundation for In- Home Therapy rate.

17. 17 Ambulatory Services: Family Counseling Notes: ● Productivity standard was calculated by taking standard 2080 yearly fiscal hours of work per employee and backing out non -direct service hours made up of: vacation, sick & personal time, holidays, training, supervision, 2 hours/week travel time, and 6hrs/week administrative (paperwork). ● Staffing ratios are consistent with outpatient counseling model. ● Tax and fringe, administrative allocation and the cost adjustment factor are consistent with other outpatient services models.

18. 18 Ambulatory Services: Day Treatment Notes: ● Divisor is yearly days at 250 (excludes 10 holidays) with the assumption of 10 clients per day. ● Direct care non-master’s staff were identified as the primary staff and were set at 1.00 FTE. All other FTEs were set based on purchaser recommendations. ● Tax and fringe, administrative allocation and the cost adjustment factor are consistent with other outpatient services models.

19. 19 Ambulatory Services: Recovery Coaching Notes: ● The productivity standard is consistent with the Case Management Master’s model. ● Staffing ratios are consistent with Case Management Master’s model with one exception. In this model, the primary staff set was identified as recovery coach and set at 1.00 FTE. ● Tax and fringe, administrative allocation and the cost adjustment factor are consistent with other outpatient services models.

20. 20 Ambulatory Services: Psycho-Educational Groups Notes: ● Productivity standard was calculated by taking standard 2080 yearly fiscal hours of work per employee and backing out non -direct service hours made up of: vacation, sick & personal time, holidays, training, supervision, 2 hrs/week travel time, and 3 hrs/week administrative (paperwork). ● Direct Care Non-Master’s staff were identified as the primary staff and were set at 1.00 FTE. All other staffing ratios are consistent with Clinical Case Management Non-Master’s model. ● Tax and fringe, administrative allocation and the cost adjustment factor are consistent with other outpatient services models. ● Hourly rate is based on one hour and twenty minutes of staff time for a one hour session for a group of five people.

21. 21 Ambulatory Services: Telephone Recovery Notes: ● Productivity standard was calculated by taking standard 2080 yearly fiscal hours of work per employee and backing out non -direct service hours made up of: vacation, sick & personal time, holidays, training, supervision, no travel time, and 3 hrs/week administrative (paperwork). ● Staffing ratios are consistent with Case Management Non-Master’s model. ● Tax and fringe, administrative allocation and the cost adjustment factor are consistent with other outpatient services models.

22. 22 Agenda Chapter 257 of the Acts of 2008 Overview Definition and Overview of Programs Procurement Approach Review of Pricing Analysis and Methodologies Components Under Ambulatory Services Current Rate Set Components Current Department Set Components Proposed Components Model Budgets Timeline and Key Milestones

23. 23 Department Service Design Finalized: All service components, staffing ratios, staff qualifications, other program inputs have been decided by the purchasing department. Provider Sessions: For each rate review, EOHHS conducts a provider input sessions to allow for greater depth in understanding changes in core program components, cost drivers, and procurement considerations. Executive Sign-Off: Commissioner and C257 Executive Committee sign-off on draft rates and implementation plan. EO485 Submitted to ANF: Draft rate regulation to ANF; Will better align the rate regulation proposal with budget planning. Public Hearing: EHS, CHIA and DPH consider testimony in advance of rate adoption. Procurement Process: The procurement will be issued after the new rates have been adopted. Rates Effective: Start date of new contracts. Projected start date of contracts is 7/1/2014. Updated Implementation Timeline and Key Milestones for Ambulatory Services

24. 24 Questions/Feedback Please Email Questions & Comments to: eohhspospolicyoffice@state.ma.us Please Visit the Chapter 257 Website: www.mass.gov/hhs/chapter257