Children's System MCO Contracting Fair November 6, 2017
2 November 7, 2017 Guiding Principles Behind Children’s Health and Behavioral Health MC Transition Key components of the managed care transition is to: • Early identification and intervention • Family-driven and youth-guided care planning and care management • Focus on resilience for children and recovery for young adults building resilience • Establish trauma informed care principles across the entire service delivery system • Ensure consumers have access to a robust network of providers within each MCO service area; • Promote financial stability through payment and claiming requirements; Network contracting activities are foundational to achieving these principles. MCOs are required to comply with key requirements that are designed to promote network development and protect the services system from disruption.
3 November 7, 2017 Medicaid Managed Care Requirements: Payment Protections Government Rates • MCOs are required to pay the APG or government rate for all OMH licensed and OASAS certified ambulatory behavioral health services, as well as BH HCBS to Medicaid eligible enrollees unless an alternative payment arrangement is approved by the Department. • This mandate extends beyond clinic services paid at APGs. Alternative Payment Permission • The alternative payment arrangement may be a shared savings arrangement and must achieve quality and efficiency objectives, i.e., value based payment.
4 November 7, 2017 Medicaid Managed Care Requirements: Utilization Management Utilization Management (UM) and Service Level of Care Determinations • Service Authorization Determinations for services must be made in accordance with utilization management criteria and service level of care guidelines issued and/or approved by the State. • No Utilization Management for 90 days from carve-in on any services under this transition
5 November 7, 2017 Medicaid Managed Care Requirements: Continuity of Care For children transitioning to Medicaid Managed Care 7/1/18: • Services in POC for HCBS or LTSS, including provider, continue unchanged for at least 180 days • No prior authorization/UM for new children’s SPA for aligned HCBS added to POC in first 180 days • Continue with current provider for BH or Medical Episode of Care for 24 months • MCOs must offer single case agreements if providers are out of network For FFS Children in receipt of HCBS that move to MMC between 7/1/18 and 6/30/20: • Services in POC for HCBS or LTSS continue for 180 days from enrollment • Continue with current provider for BH Episode of Care
6 November 7, 2017 Medicaid Managed Care Requirements: Network Development MCOs are required to offer contracts to: • OMH/OASAS providers with 5 or more under 21 enrollees • Allied providers of OASAS residential programs • Licensed Integrated clinics for full range of services • All licensed school based mental health clinics in plan service area • Designated providers of children’s services (former 1915 -c providers – for EACH population for EACH service) • Children’s Health Homes • Providers with high volume of single case agreements
7 November 7, 2017 Medicaid Managed Care Requirements : Provider Credentialing Children’s Provider Designation Meets MCO Credential Requirements • This provision directs the plan to accept the NYS Children’s HCBS/ State Plan designation to satisfy the plans credentialing; plan is still required to collect and accept program integrity related information as required by the State Contract and Medicaid regulations OMH/ OASAS Certification Meets MCO Credential Requirements • Directs the plan to credential the OMH licensed and OASAS certified program and that the license / certification shall suffice for plan contracting requirements and that the plan may not separately credential individual staff members. The contract requires that the plans shall still collect, accept, and review Medicaid program integrity related information as required by the State Contract and Medicaid regulations.
8 November 7, 2017 Medicaid Managed Care Requirements : All Products Prohibition The Plan is prohibited from conditioning the participation of a BH provider upon agreement to participate in a Plan’s non -Medicaid line(s) of business.
9 November 7, 2017 Managed Care Provider Contracting Lessons Learned • Be aware of “ lesser of” language which should not exist • All MCOs should pay based on OMH/OASAS posted rate codes and procedures – some plans might attempt to list out (limit) the codes they pay • For UM authorizations, Plans and Providers must follow units as outlined by OMH Coding Taxonomy. If provider is not doing it correctly, claims will deny • Authorization letter is not a guarantee of claims payment, ensure you follow listed coding guidelines • Ensure the services you are contracted to provide are accurately listed in the MCO contract • Confirm that you are contracted with Medicaid line of business. There has been confusion where providers are contracted with multiple lines of business (Medicaid/ Medicare/ Commercial/ MLTC) • Plan notification: Provide MCO with a list of clients currently in service for: • 90 day transition period • Communicate with the plans this information
10 November 7, 2017 Managed Care Provider Contracting Lessons Learned • As part of the contracting process BH providers are encouraged to: • Review contracts and strike or amend any conflicting contractual language where possible; and, • Add language consistent with the following: “For purposes of the Behavioral Health transition, where any terms of this Agreement contradict or conflict with terms in the State Managed Care Model Contract and corresponding guidelines, the Managed Care Model Contract and guidelines shall prevail.” • OMH providers are encouraged to review current and proposed amendments to provider agreements for consistency with the proposed Medicaid Managed Care Model Contract provisions outlined in this presentation • Providers are strongly encouraged to finalize contracting with plans to ensure inclusion in Medicaid Managed Care provider networks prior to the effective date of the benefit expansion • Providers are strongly encouraged to sign single case agreements in the cases of continuity of care to ensure there is no disruption in the delivery of service or payment • Single case agreements must also protect laws of government rates for ambulatory services • Utilization management rules apply under a single case agreement
11 November 7, 2017 MCO Claims Testing Before claims testing can begin: • Providers need to be contracted & credentialed (a Full Network Provider) • If you’re already a Full Network Provider, you need to add Children’s services to your contract, and be credentialed for those services Even if you have experience billing Managed Care, it is strongly recommended that you still claims test for Children’s Services
12 November 7, 2017 Managed Care Contracting Resources for Providers Source Document Contract Protection “Per the Medicaid Managed Care Model Contract, MCOs must reimburse ambulatory behavioral BH Policy Guidance health providers licensed or certified by OMH or OASAS, including Comprehensive Psychiatric – Emergency Programs and the Extended Observation Beds included in these programs and out of https://www.health.ny.gov/health_care/ network providers, at Medicaid Fee for Service rates for 24 months.” medicaid/redesign/behavioral_health/rela ted_links/docs/bh_policy_guidance_10-1- 15.pdf “New York State law currently requires that Medicaid MCOs pay the equivalent of Ambulatory BH Billing Manual – Patient Group (APG) rates for OMH licensed mental health clinics. Beginning October 1, 2015 in https://www.omh.ny.gov/omhwe NYC and July 1, 2016 in counties outside of NYC, Plans will be required to pay 100% of the b/bho/harp-mainstream-billing- Medicaid fee-for- May 18, 2017 OMH/OASAS Behavioral Health Billing Manual for Medicaid manual.pdf Managed Care Plans and HARPS Page 4 service (FFS) rate (aka, “government rates”) for selected behavioral health procedures (see list below) delivered to individuals enrolled in mainstream Medicaid managed care plans, HARPs, and HIV Special Needs Plans (SNPs) when the service is provided by an OASAS and OMH licensed, certified, or designated program. This requirement will remain in place for the first two years (based on the regional carve-in/implementation schedule).”
Recommend
More recommend
