Transcript Residential Services

Drug Medi-Cal
Organized Delivery System
Waiver
1
DMC Benefits Prior to ACA
• Mandatory Population Only
• Modalities
– Outpatient Drug Free (ODF) - all mandatory
populations
– Narcotic Treatment Programs (NTP) - all mandatory
populations
– Residential (perinatal only in non-IMDs)
– Intensive Outpatient Therapy (IOT) - perinatal only
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ACA Expansion
• Increased Eligible Beneficiaries
(Expanded Population)
• CA chose to expand modalities
– IOT (for Mandatory and Expanded
Populations)
– Residential (for Mandatory and Expanded
Populations)
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ACA Expansion
Residential Services
• Residential needed in the continuum of care
• Restricted due to the Institute for Mental Disease
(IMD) exclusion
• Ninety percent of California’s residential bed capacity
is considered an IMD
• Clients in IMD’s restricted from all MediCal services
• Without the DMC-ODS Waiver Pilot, California
cannot provide residential services
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Development of DMC-ODS
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Conducted a SUD Needs Assessment
Program Integrity Issues
Physical and Behavioral Health Integration
Merging of Departments
Screening Brief Intervention and Referral
Treatment in Managed Care (SBIRT)
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Stakeholder Process
• January 2014- DHCS began the
stakeholder engagement process
• April 2014- DHCS held three Waiver
Advisory Group (WAG) meetings
• July 2014- DHCS released draft Standard
Terms and Conditions (STCs)
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Stakeholder Process
• Additional WAGs were held in July 2014,
January 2015, Feb 2015 and March 2015
• Participants: counties, provider associations,
Alcohol and Other Drug counselor certifying
organizations, managed care health plans,
public interest advocates, and legislature
• Meeting notes posted on the website
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DMC Organized Delivery System Waiver
• The goal is to improve Substance Use Disorder
(SUD) services for California beneficiaries
• Authority to select quality providers
• Consumer-focused; use evidence based
practices to improve program quality outcomes
• Support coordination and integration across
systems
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DMC Organized Delivery System Waiver
• Reduce emergency rooms and hospital
inpatient visits
• Ensure access to SUD services
• Increase program oversight and integrity
• Provide availability of all SUD services
• Place client in the least restrictive level
of care
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DMC Organized Delivery System Waiver
DMC Services
SPA 13-038 ( NonWaiver
Opt-in Waiver
Outpatient/Intensive
Outpatient
X
X
NTP
X
X
Residential
X (one level)
Withdrawal Management
X (one level)
Recovery Services
X
Case Management
X
Physician Consultation
X
Additional MAT
X (optional)
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General Provisions
• Amendment to Bridge to Reform and
folded into MediCal 2020 1115 Waiver
• Pilot for 5.5 years
• Does not require a change in Statute or
regulations
• Counties choose to opt-in
• 53 of 58 counties expressed an interest
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Early Intervention Services
• SBIRT (screening, brief intervention and
referral to treatment) American Society of
Addiction Medicine (ASAM) Level 0.5
• Provided by non-DMC providers to
beneficiaries at risk of SUD (through FFS
system)
• Referrals by managed care providers or
plans to DMC-ODS will be governed by the
Memorandum of Understanding
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Outpatient
• ASAM Level 1
• Individual and group counseling up to 9 hours a
week for adults
• Determined by a Medical Director or Licensed
Practitioner of the Healing Arts (LPHA)
• Services can be provided in-person, by
telephone or by telehealth (except group)
• Addition of family therapy
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Intensive Outpatient
• ASAM Level 2.1
• Minimum of nine hours with a maximum of
19 hours a week for adults
• Determined by a Medical Director or LPHA
• Services can be provided in-person, by
telephone or by telehealth (except group)
• Addition of family therapy
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Partial Hospitalization
• ASAM Level 2.5
• 20 or more hours of clinically intensive
programming per week
• Providing this level of service is optional
for participating counties
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Residential
• 5 Levels of Residential Based on ASAM
(Levels 3.1, 3.3, 3.5, 3.7 and 4.0)
• One level required for DMC-ODS
• No bed capacity limit
• The length of residential services range
from 1 to 90 days with a 90-day maximum
for adults
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Residential
• Medical necessity can authorize a one-time
extension of up to 30 days on an annual basis
• Only two non-continuous 90-day regimens will
be authorized in a one-year period
• Perinatal clients may receive a longer length
of stay based on medical necessity
• CDRH and Acute Free Standing Psych paid
through the FFS system
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Withdrawal Management
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(Levels 1, 2, 3.2, 3.7 and 4 in ASAM)
Determined by a Medical Director or LPHA
Monitored during detoxification
IMD expenditure approval for Chemical
Dependency Recovery Hospitals and Free
Standing Psychiatric Hospitals (paid
through FFS system)
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Opioid (Narcotic) Treatment Program
• ASAM OTP Level 1
• Required service in all opt-in counties
• Adding buprenorphine, disulfiram and
naloxone in NTP settings
• Minimum fifty minutes of counseling
sessions up to 200 minutes per calendar
month or more with medical necessity
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Additional Medication Assisted Treatment
• The goal of the DMC-ODS for Medication
Assisted Treatment (MAT) is to open up options
for patients to receive MAT by requiring MAT
services in all opt-in counties, educate counties
on the various options pertaining to MAT and
provide counties with technical assistance to
implement any new services
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Additional Medication Assisted Treatment
Medication
Methadone
Buprenorphine
Naltrexone tablets
TAR* Required
No
Yes, unless
provided in an
NTP/OTP
No
Naltrexone long-acting
injection
Yes
Disulfiram
No
Acamprosate
Naloxone
Yes
No
Availability
Only in NTP/OTP
Pharmacy Benefit,
NTP/OTP
Pharmacy Benefit,
DMC Benefit
Pharmacy Benefit,
Physician Administered
Drug
Pharmacy Benefit,
NTP/OTP
Pharmacy Benefit
Pharmacy Benefit;
NTP/OTP
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Recovery Services
• May access recovery services after
completing the course of treatment, if
triggered, if relapsed or as a preventative
measure to prevent relapse
• Provided face-to-face, by telephone, or by
telehealth with the beneficiary and may be
provided anywhere in the community
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Case Management
• Counties will coordinate case management
services
• Services can be provided in various
locations
• Coordinate with Mental and Physical Health
• Provided face-to-face, by telephone, or by
telehealth
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Physician Consultation Services
• Physician consultation services with addiction
medicine physicians, addiction psychiatrists or
clinical pharmacists
• Designed to assist DMC physicians with
treatment plans for DMC-ODS beneficiaries
• Medication selection, dosing, side effect
management, adherence, drug-to-drug
interactions, or level of care considerations
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Criminal Justice System
• Additional Lengths of Stay (up to 6
months residential; 3 months Federal
Financial Participation (FFP) with a onetime 30-day extension)
• If longer lengths, other county identified
funds can be used
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Provider Specifications
• Addition of LPHAs: Physician, Nurse
Practitioners, Physician Assistants,
Registered Nurses, Registered Pharmacists,
Licensed Clinical Psychologist (LCP),
Licensed Clinical Social Worker (LCSW),
Licensed Professional Clinical Counselor
(LPCC), and Licensed Marriage and Family
Therapist (LMFT)
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County Responsibilities
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Selective Provider Contracting
Access to Services
Medication Assisted Treatment
Contracting Requirements
Provider Appeals Process
Residential Authorization
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County Responsibilities
• County Implementation Plan
• County Fiscal Plan
• Two Evidence Based Practices
(motivational interviewing, CognitiveBehavioral Therapy, Relapse Prevention,
Trauma-Informed Treatment, PsychoEducation)
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County Responsibilities
• MOU with all managed care providers
– Comprehensive Screening
– Beneficiary Engagement
– Shared Plan Development/Treatment Planning
– Case Management Activities
– Dispute Resolution
– Care Coordination/Referral Tracking
– Navigation Support
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County Responsibilities
• Beneficiary Access Number
• Care Coordination with Mental and
Physical Health Services
• State/County Contract
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State Responsibilities
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Integration Plan
Innovation Accelerator Program
ASAM Designation for Residential facilities
Oversee Provider Appeals Process
Monitoring Plan
– Timely Access
– Program Integrity
– Triennial Reviews
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Quality Improvement
• Counties must have:
– QI Plan
– QI Committee
– Review Accessibility of Services Data
– Utilization Management Program
– Participate in Annual External Quality
Reviews
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Financing
Rates
• Counties will negotiate provider rates by
modality (except for NTP Services which
will remain set by DHCS)
• The state will have final approval of the
rates
• If the state rejects the rates, the county
can resubmit revised rate
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Financing
Realignment
• Counties receive realignment funds
derived from sales tax revenues
deposited into their Behavioral Health
Subaccount to pay for a portion of DMC
treatment services
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Financing
• The cost of all DMC Waiver services will
be shared among the federal government,
State government and the counties
• The Federal government will continue to
pay FFP for the existing population
(mandatory) at the 50% rate (including
residential services)
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Financing
• The Federal government will pay FFP for
the expansion population at the applicable
enhanced rate (including residential),
currently 100%, decreasing to 95% in
2017, and so on until reaching 90% in
2020 and beyond
• Sharing Ratio is county specific
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Financing
• The non-federal share will be split
between the State/County based on a
county-specific State/County sharing ratio
• Quality Assurance Activities will be
reimbursed at 75% FFP
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Financing
• The sharing ratio will apply to outpatient,
intensive outpatient, NTPs (including
buprenorphine and disulfiram), recovery
services, case management, physician
consultation, residential, quality assurance
activities, and county administration
services
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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
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Federal 438 Requirements
• Counties held to all federal 42 CFR 438
requirements (quality assurance,
beneficiary protections, access)
• External Quality Review requirements
must be phased in within 12 months of
having an approved implementation plan
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Tribal Delivery System
• DHCS will consult with the tribes and the
four tribal 638/urban programs after
approval of the amendment
• Phase 5 implementation will focus on the
tribal system after the amendment has
been approved by CMS
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DMC-ODS Waiver Implementation
• Regional Implementation
Phase I – Bay Area (May-August 2015)
Phase II – Southern California
Phase III – Central Valley
Phase IV – Northern California
Phase V – Tribal Delivery System
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DMC-ODS Waiver Implementation
• Next Waiver Advisory Group Meeting
– Between Phase One and Two
• County Regional Waiver Meetings
– Phase One meeting: May 2015
– Phase Two meeting: October 2015
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DMC-ODS Waiver Implementation
Technical Assistance from DHCS
• State Implementation Plan
• Designing a Training Plan
• DHCS Substance Use Disorders
Statewide Conference
“Organizing the SUD Delivery System”
October 26-27, 2015
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Implementation Responsibilities
PTRS Division
• IT Changes to Short-Doyle
• State/County Contract
• DMC Monitoring Protocol
Provider Enrollment Division
• DMC Certification
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Implementation Responsibilities
SUD Compliance Division
• County and Fiscal Implementation Plans
• Provider Appeals Process
• ASAM Designation for Residential
• External Quality Review Organization
• Expansion of MAT
• Coordinate WAGs and EAGs
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Implementation Responsibilities
SUD Compliance Division
• UCLA Evaluation
• Training Plan and Contract
• Technical Assistance
• County Liaisons
• Integration Plan
• CMS- Innovation Accelerator Program
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DMC-ODS Waiver Implementation
• DHCS DMC-ODS Website
• http://www.dhcs.ca.gov/provgovpart/Pages
/Drug-Medi-Cal-Organized-DeliverySystem.aspx
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