1. Drug Medi-Cal Organized Delivery System Pilot Program
DHCS Stakeholder Webinar
October 22, 2015

2. Overview of Presentation
Impact of Substance Use
Federal Landscape
Goals and Objectives of the Pilot
Stakeholder Process
Waiver Authority
Critical Elements
Standard Terms and Conditions
Evaluation
Regional Implementation
October 22, 2015

3. Presenters Karen Baylor, PhD, Deputy Director, MHSUD, DHCS
Marlies Perez, Division Chief, MHSUD, DHCS
Don Kingdon, PhD, Harbage Consulting
Molly Brassil, Harbage Consulting
October 22, 2015

4. Impact of Substance Use
Substance use disorders (SUDs) occur when the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home
About 21.5 million Americans ages 12 and older (8.1%) are classified with a SUD (SAMHSA, 2014)
Untreated SUDs are associated with increased risks for a variety of costly chronic physical and mental healthcare conditions, avoidable hospitalizations, incarceration, and premature death
Addressing the impact of substance use alone is estimated to cost Americans more than $600 billion each year (SAMHSA, 2014)
Since 1999, opiate overdose deaths have increased 265% among men and 400% among women (SAMHSA, 2015)
October 22, 2015

5. Federal Landscape
States have a tremendous opportunity to improve access to care for individuals with SUDs, particularly in light of the coverage and benefit expansions under the Affordable Care Act (ACA).
Mental health and SUD services are notably included as one of ten essential health benefits that must be covered under Medicaid alternative benefit plans and Health Insurance Marketplace qualified health plans, with parity to covered medical and surgical services.
Although millions of adults across the country now, many for the first time, have health insurance that covers SUD services, most state delivery systems and benefit structures for treatment have historically been inadequate for the Medicaid population.
To date, most state Medicaid programs have only covered a minimal number of services, have insufficient provider networks, and few standards for this type of care.
October 22, 2015

6. Federal Landscape
The Centers for Medicare & Medicaid Services (CMS) issued guidance in July 2015 outlining the opportunities for states to design service delivery systems for Medicaid beneficiaries with substance use disorders.
Includes a new section 1115 waiver opportunity to build a robust continuum of care for beneficiaries with substance use disorders.
Strategies can also include short-term institutional services, such as short-term inpatient and short-term residential SUD services for individuals in institutions for mental disease (IMD).
California is the first 1115 project approved under this guidance.
October 22, 2015

7. California’s Goals and Objectives
To test a new paradigm for the organized delivery of health care services for Medi-Cal enrollees with a substance use disorder
Will demonstrate how organized SUD care improves outcomes for DMC beneficiaries while decreasing other system health care costs
Promote both systemic and practice reforms to develop a continuum of care that effectively treats the multiple dimensions of substance use disorders
Design a SUD benefit that guarantees a full continuum of evidence- based practices to address the immediate and long-term physical, mental, and care needs of the beneficiary
October 22, 2015

8. Stakeholder Process
DHCS held nine Waiver Advisory Group meetings in 2014 and 2015 to inform the development of the pilot proposal to CMS
Participants have included counties, provider representatives, Alcohol and Other Drug counselor certifying organizations, Medi-Cal managed care plans, public interest advocates, the Legislature, and others
Meeting notes / materials posted on the website:
October 22, 2015

9. Critical Elements of Pilot Program
Critical Elements of the DMC-ODS Pilot Program include:
Continuum of care modeled after ASAM
Increased local control and accountability
Greater administrative oversight
Utilization tools to improve care and manage resources
Evidence-based practices
Coordination with other systems of care
Special considerations for the criminal-justice involved population
October 22, 2015

10. Waiver Authority
The DMC-ODS Pilot Program is authorized and financed under the authority of the state’s 1115 Bridge to Reform Waiver.
The purpose of 1115 waivers is to demonstrate and evaluate policy approaches that improve care, increase efficiency, and reduce costs.
Demonstrations must be “budget neutral,” which means that during the course of the project federal Medicaid expenditures will not be more than fed spending without the waiver.
The DMC-ODS Pilot Program will be elective for 5 years.
October 22, 2015

11. Standard Terms and Conditions
Eligibility
Benefits
County Responsibilities
State Oversight, Monitoring & Reporting
Fiscal Framework
October 22, 2015

12. Eligibility No age restrictions Adults: Enrolled in Medi-Cal
Reside in Participating County
Meet Medical Necessity Criteria:
One DSM Diagnosis for substance-related and addictive disorders (with the exception of tobacco)
Meet ASAM criteria definition of medical necessity for services based on ASAM criteria
October 22, 2015

13. Eligibility Youth: Enrolled in Medi-Cal Reside in Participating County
Meet Medical Necessity Criteria:
Be assessed to be at risk for developing a substance use disorder
Meet the ASAM adolescent treatment criteria (if applicable)
October 22, 2015

14. Benefits
The continuum of care for SUD services is modeled after levels identified in the ASAM criteria
Counties are responsible for most levels; however, a few of them are overseen / funded by other sources
Counties may implement a regional model with other counties
Counties may contract with providers in other counties in order to provide the required services
October 22, 2015

15. Benefits – Standard vs. Pilot
Standard DMC services approved through the state plan benefit will be available to all beneficiaries in all counties.
Beneficiaries that reside in a Pilot county receive DMC-ODS benefits in addition to other state plan services.
County eligibility is based on the MEDs file.
In counties that do not opt in, beneficiaries receive only those drug and substance use disorder treatment services outlined in the approved state plan (including EPSDT).
Beneficiaries receiving services in non-opt in counties will not have access to the services outlined in the DMC-ODS.
October 22, 2015

16. Standard Benefits
Existing Statewide Medi-Cal SUD Treatment Services Include:
Outpatient Drug Free Treatment
Intensive Outpatient Treatment
Naltrexone Treatment (with TAR)
Narcotic Treatment Program
Perinatal Residential SUD Services (limited by IMD exclusion)
Detoxification in a Hospital (with TAR)
These benefits will remain available to all Medi-Cal beneficiaries, including those in non-pilot counties
October 22, 2015

17. Pilot Benefits DMC-ODS Pilot Counties are required to provide:
Early Intervention (coordination with FFS / MCPs)
Outpatient Services (includes IOT and naltrexone)
Residential (not limited to perinatal or restricted by IMD exclusion)
Narcotic Treatment Program
Withdrawal Management (at least one level)
Recovery Services
Case Management
Physician Consultation
The following levels of service are optional for pilot counties:
Partial Hospitalization (optional)
Additional Medication Assisted Treatment (optional)
October 22, 2015

18. New Benefits Recovery Services Case Management Physician Consultation
Focus on building beneficiary’s self-management skills and linking to community resources.
May be accessed after completing course of treatment (if triggered, relapsed, or to prevent relapse)
Case Management
To assist a beneficiary to access necessary medical, educational, social, prevocational, vocational, rehabilitative, or other community services.
Physician Consultation
DMC physicians consulting with addiction medicine physicians, addiction psychiatrists, or clinical pharmacists to offer support with complex cases (i.e. medication selection, dosing, side effect management, adherence, drug-drug interactions, or level of care considerations)
October 22, 2015

19. Residential Services
Non-institutional, 24-hour, non-medical, short-term residential program that provides rehabilitative services
Often requires treatment that is primarily slower-paced, more concrete and repetitive in nature, with structured patterns of activities intended to restore cognitive functioning and build behavioral patterns within a community.
Each beneficiary lives on the premises and shall be supported in their efforts to restore, maintain, and apply interpersonal and independent living skills and access community support systems.
Goals include sustaining abstinence, preparing for relapse triggers, improving personal health and social functioning, and engaging in continuing care.
October 22, 2015

20. Residential Services - Today
CA’s state plan currently limits residential SUD services to perinatal beneficiaries
Federal matching funds are only available for services provided in facilities not considered IMDs (i.e. 16 bed max)
Ninety percent of California’s residential bed capacity is considered an IMD
No coverage of residential SUD services for non-perinatal beneficiaries (by Drug Medi-Cal)
Limited services offered by some counties using local resources / federal grant funding
October 22, 2015

21. Residential Services - Pilot
Services are provided to non-perinatal and perinatal beneficiaries
No bed capacity limit (i.e. 16 bed IMD exclusion does not apply)
Provided in DHCS licensed & certified residential facilities that also have been designated by DHCS to meet ASAM treatment criteria
90 day max length of stay for adults; 30 days for adolescents (with one time 30 day extension)
Criminal justice and perinatal pops eligible for longer stays
Counties must provide authorization for residential services within 24 hours of submission of the request
October 22, 2015

22. County Responsibilities
Selective Provider Contracting
Access
Selection Criteria
Contract Denial / Appeal Process
Provider Requirements
Authorization for Residential
Beneficiary Access Number (24/7 toll free)
Beneficiary Informing (upon first contact)
Care Coordination
Quality Improvement / Utilization Management
County Implementation Plan / Contract
October 22, 2015

23. Access
Each county must ensure that all required services covered under the pilot are available and accessible to enrollees.
If the county is unable to provide services, the county must cover out-of-network.
Access to state plan services (existing benefits) must remain at the current level or expand upon implementation of the Pilot.
The county shall maintain and monitor a network of appropriate providers that is supported by contracts with subcontractors and sufficient to provider adequate access.
October 22, 2015

24. Access
In establishing and monitoring the network, the county should consider:
Process to require its providers to meet standards for timely access to care as specified in the county implementation plan and contract
Anticipated number of Medi-Cal eligible clients
Expected utilization of services
Expected number and types of providers in terms of training & experience needed
Providers accepting new Medi-Cal clients
Geographic location of providers
October 22, 2015

25. Provider Requirements
Pilot counties will include the following requirements in their provider contracts:
Provide culturally competent services, including translation services, as needed.
Procedures for coordination of care for enrollees receiving MAT services.
Implement at least two (2) of the following Evidence Based Practices:
Motivational Interviewing
Cognitive-Behavioral Therapy
Relapse Prevention
Trauma-Informed Treatment
Psycho-Education
October 22, 2015

26. Care Coordination
Pilot counties must describe care coordination plan for achieving seamless transitions of care.
Pilot county shall enter into a MOU with any health plan that enrolls beneficiaries served by DMC-ODS. MOU to include:
Comprehensive Screening
Beneficiary Engagement
Shared Plan Development/Treatment Planning
Case Management Activities
Dispute Resolution
Care Coordination/Referral Tracking
Navigation Support
October 22, 2015

27. Quality Each pilot county must have a Quality Improvement (QI) Plan
County shall have a QI Committee
Shall review data quarterly
County shall have a Utilization Management Program
Must have a system for collecting, maintaining, and evaluating accessibility of care and waiting list information
October 22, 2015

28. Implementation Plan & Contract
Counties must submit to the state a plan for implementation of the DMC-ODS pilot (boilerplate plan included in STCs).
Plan to be approved by both DHCS and CMS.
County must also have an executed state/county contract (intergovernmental agreement) subject to county Board of Supervisors and CMS approval.
At least 60 days prior to CMS contract approval, state shall submit applicable network adequacy requirements for each opt-in county.
Upon approval of the plan and executed contract, counties will be able to bill prospectively for services through this pilot.
October 22, 2015

29. State Responsibilities
Integration Plan
Innovation Accelerator Program
ASAM Designation for Residential Facilities
Provider Appeals Process
Monitoring Plan
Annual EQRO Review
Timely Access
Program Integrity
Reporting of Activity
Triennial Report
October 22, 2015

30. Fiscal Provisions
Counties will certify the total allowable expenditures incurred in providing DMC-ODS pilot services through county operated or contracted providers
Counties will develop proposed county-specific rates for each covered service (except for NTP) subject to state approval
The county will have an opportunity to adjust the proposed rates and resubmit to the state
2011 Realignment requirements related to the Behavioral Health Subaccount will remain in place and the state will continue to assess and monitor county expenditures for the realigned programs
October 22, 2015

31. Fiscal Provisions Cont.
The CMS-approved CPE protocol, based on actual allowable costs, is still in development and must be finalized before FFP will be made available to the state and counties
The counties may also pilot alternative reimbursement structures subject to standards to be established by the state
Subject to annual state budget appropriation the state also intends to provide payments to participating counties for a state share of the costs for program implementation
October 22, 2015

32. Evaluation
University of California, Los Angeles, (UCLA) Integrated Substance Abuse Programs will conduct the evaluation
Four key areas of access, quality, cost, and integration and coordination of care
October 22, 2015

33. Regional Implementation
Phase I – Bay Area
Phase II – Southern California
Phase III – Central Valley
Phase IV – Northern California
Phase V – Tribal Delivery System
October 22, 2015

34. Statewide SUD Conference
Upcoming Events
Statewide SUD Conference
October 26-27, 2015
Orange County, CA
October 22, 2015

35. Department of Health Care Services
Karen Baylor, PhD, Deputy Director, MHSUD, DHCS
Marlies Perez, Division Chief, MHSUD, DHCS
For More Information: Organized-Delivery-System.aspx
October 22, 2015

36. Harbage Consulting
Don Kingdon, PhD, Director of Behavioral Health Integration
Molly Brassil, MSW, Deputy Director, Behavioral Health Integration
Courtney Kashiwagi, MPH, Senior Consultant
October 22, 2015