Managed Care: Overview of Behavioral Health Services Transitioning to Medicaid Managed Care on July 1, 2019 June 7, 2019
Introduction & Housekeeping Reminders ‣ Slides and recording will be posted at MCTAC.org ‣ Information and timelines are current as of the date of the presentation ‣ This presentation is not an official document. For full details please refer to the provider and billing manuals
Children’s Medicaid Overview of Key Components
Key Components of Children’s Medicaid System Transformation ‣ Six New State Plan Services for Children (Three services began in January 2019) ‣ Transition to Health Home Care Management (Occurred April 1, 2019) ◦ Current 1915(c) Waiver Providers Transition to Health Home ◦ Care Management provided under 1915(c) Transition to Health Home Care Management ‣ Transition of six 1915(c) waivers to 1915c Waiver authority under one consolidated Children’s Waiver (Occurred April 1, 2019): ◦ Office of Mental Health (OMH) Serious Emotional Disturbance (SED) Waiver ◦ Department of Health (DOH) Care at Home (CAH) I/II waiver ◦ Office for People with Developmental Disabilities (OPWDD) Care at Home Waiver ◦ Office of Children and Families (OCFS) Bridges to Health (B2H) SED, Developmental Disability (DD) and Medically Fragile Waivers
Key Components of Children’s Medicaid System Transformation ‣ Alignment of 1915(c) HCBS under one array of Home and Community Based Services (HCBS) authorized under 1115 Demonstration Waiver (Planned for October 1, 2019; Pending CMS Approval) ◦ Remove the Managed Care exemption for children now in six 1915(c) waivers ‣ Lifting the exemption of children in foster care with Voluntary Foster Care Agency (VFCA) to Managed Care (Planned for October 1, 2019; Pending CMS Approval) ‣ Transition of certain carved out Behavioral Health services into Managed Care benefit package (July 1, 2019)
Timeline Update Children’s Transition Timeline Scheduled Date • Implement three of the six new Children and Family Treatment and Support Services (CFTSS) (Other Licensed January 1, 2019 Practitioner, Psychosocial Rehabilitation, Community Psychiatric Treatment and Supports) in Managed Care and Fee- COMPLETED For-Service • Waiver agencies must obtain the necessary LPHA recommendation for CFTSS that crosswalk from historical waiver January 31, 2019 services and revise service names in Plan of Care for transitioning waiver children. This is the last billable date of COMPLETED waiver services that crosswalk to CPST and/or PSR. • Transition from Waiver Care Coordination to Health Home Care Management January 1- March 31, 2019 COMPLETED • 1915(c) Children’s Consolidated Waiver is effective and former 1915c Waivers no longer active April 1, 2019 COMPLETED • Implement Family Peer Support Services as State Plan Service in managed care and fee-for-service July 1, 2019 • BH services already in managed care for adults 21 and older are available in managed care for eligible individuals under July 1, 2019 21 (e.g. PROS, ACT, etc.) • OMH licensed SED designated clinics serving children with SED diagnoses are carved-in to managed care July 1, 2019 • SSI children begin receiving State Plan behavioral health services in managed care July 1, 2019 • Three-year phase in of Level of Care (LOC) expansion begins July 1, 2019 • 1915(c) Children’s Consolidated Waiver Services carved -in to managed care October 1, 2019 • Children enrolled in the Children’s 1915(c) Waiver are mandatorily enrolled in managed care October 1, 2019 • Voluntary Foster Care Agency Article 29-I per diem and services carved-in to managed care October 1, 2019 • Children residing in a Voluntary Foster Care Agency are mandatorily enrolled in managed care October 1, 2019 • 29-I Licensure becomes effective for Voluntary Foster Care Agencies October 1, 2019 • Implement Youth Peer Support and Training and Crisis Intervention as State Plan services in managed care and fee-for- January 1, 2020 service Managed care services and enrollment are pending CMS approval
Transition of Existing State Plan Behavioral Health Services to Managed Care for Children
Services Carved-In to Medicaid Managed Care on July 1, 2019 ‣ Behavioral health services already in managed care for adults 21 and older will be carved in for eligible individuals under 21 • Assertive Community Treatment (ACT) • Comprehensive Psychiatric Emergency Program (CPEP) (including Extended Observation Bed) • Personalized Recovery Oriented Services (PROS) • Continuing Day Treatment (CDT) • OASAS Outpatient and Opioid Treatment Program (OTP) services (hospital based) • OASAS Outpatient Rehabilitation Services (hospital based) • Partial Hospitalization
Services Carved-In to Medicaid Managed Care on July 1, 2019 ‣ Behavioral health State Plan services for children who have federal Social Security Insurance disability status or have been determined Social Security Insurance-Related by New York State (SSI children) ‣ OMH specialty clinics designated for MMC enrolled children who have met criteria for a serious emotional disturbance (SED) Please note: Medicaid/Medicare children (dually eligible) are not being carved in during this transition.
What Does This Mean? ‣ Effective July 1, 2019, these services for eligible children under age 21 will be part of the MMCP benefit package and claiming will follow billing procedures defined in New York State Health and Recovery Plan (HARP) / Mainstream Behavioral Health Billing and Coding Manual: https://www.omh.ny.gov/omhweb/bho/harp-mainstream-billing-manual.pdf ‣ Providers must ensure necessary authorization is in place for services provided after July 1, 2019. • Providers should begin checking managed care enrollment for all individuals served who are under 21, and should contact those individuals’ MMCPs to ensure authorizations are place.
Continuity of Care ‣ Children and youth under 21 can continue to see their same providers for up to 24 months for a continuous episode of care, regardless of whether the provider is in the child’s Plan’s network ‣ For the services covered in this presentation, Plans should ensure authorizations are provided for existing providers/service level for up to 60 days from the carve in date to ensure there are no gaps in coverage or access to services, until the provider and the Plan have established an arrangement for continued services • This means that providers must work with Plans prior to 7/1/19 but no later than 60 days after 7/1/19 to ensure authorizations are in place for continued services • This requirement does NOT prohibit Plans from conducting utilization management on these services
Assertive Community Treatment (ACT)
Referrals to ACT ‣ Level Of Service Determination (LOSD) • NYC & ROS (see ACT Utilization Management Guidance) • Referring provider contacts MCO • MCO UM staff review to ensure individual meets ACT level of care admission criteria • MCO notifies of LOSD within 24 hours
ACT Authorization and Concurrent Review ‣ Authorization - the accepting ACT team will contact the MCO within seven (7) days prior to the date of admission to obtain the prior authorization and determine a timeframe for concurrent review ‣ Concurrent Reviews - recommend aligning with OMH required concurrent review with assessment and service plan dates (6-months) • Most individuals who are appropriate for ACT level of care will require services for a period of at least 2-3 years and many will require an even longer duration • It is expected that the intervals for UM should reflect the longer-term nature of the service.
Billing for ACT ‣ ACT claims are submitted using the last day of the month, in which the services were rendered, as the date of service (e.g. Services provided in July will submit a claim with 7/31/19 as the service date) ‣ ACT Service Authorization/Reimbursement is in “Units” only ◦ Unit = 1 month of service ‣ Three Rate Codes ◦ 4508 Full Payment ◦ 4509 Partial Payment ◦ 4511 Hospital
Overview of the ACT Model: Billing Billing: ‣ Full Rate – must provide a minimum of 6 visits per month, three 3 of which may be collateral (family, employment, landlord, etc.) ‣ Partial Rate – must provide a minimum of two 2 visits per month, but fewer than 6
Overview of the ACT Model: Billing ‣ Inpatient Rate - clients who are admitted for treatment to an inpatient facility and are anticipated to be discharged within 180 days of admission; a minimum of 2 inpatient face-to-face contacts are provided in a month • In the month of admission and/or month of discharge full payment rate reimbursement is permitted for any month in which four or more community-based contacts combined with inpatient face-to-face contacts equals six or more total contacts in the month. • In the month of admission and/or month of discharge stepdown/partial payment rate reimbursement is permitted when a minimum of two community-based contacts are provided in a month, or when a minimum of one community contact, combined with a minimum of one inpatient contact, is provided.
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