Transcript Behavioral Health Medicaid Re-Design

Medicaid Behavioral Health Redesign
Children’s Topics
OACCA Fall Conference 9.9.16
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Vision, Policy and Coverage
Outcomes
Behavioral Health Redesign Vision
OUTCOMES & VISION:
» All Providers: Follow NCCI & practice at the top of their scope of practice
» Integration of Behavioral Health & Physical Health services
» High intensity services available for those most in need
» Developing new services for individuals with high intensity service and support needs;
» Services & supports available for all Ohioans with needs: Services are sustainable within budgeted resources
» Implementation of value-based payment methodology
» Coordination of benefits across payers
» Improving health outcomes through better care coordination; and
» Recoding of all Medicaid behavioral health services to achieve alignment with national coding standards.
4
Policy and Coverage Outcomes
Added evidence-based/state-best practices and
associated payments
ACT and IHBT
Aligned SUD Benefit with ASAM levels of care
ASAM Levels of Care
No diagnosis edits for children’s services provided by
licensed practitioners
Children’s BH Services
Monitoring of cardiac health for individuals receiving BH
medications through use of EKG
EKGs
4
Policy and Coverage Outcomes
Expanded Code Set
Expanded code set and practitioner list (e.g., physicianadministered J-codes) to more accurately represent
services and practitioners
Inclusion of certain clinical laboratory tests and
vaccinations
Labs and Vaccines
*Medicaid
Medical Services
MH Professional
Experience
Office-based E&M codes at 100% of Medicare* cannot pay more
Home-based E&M codes at 100% of Medicare* than Medicare
Registered Nurse and Licensed Practical Nurse coding solution
Compliance with national correct coding
MH para-professionals with 5+ years of experience
(on or before June 30th, 2017) will be able to provide
Therapeutic Behavioral Services**
**Policy change
formalized on
June 15th, 2016
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Policy and Coverage Outcomes
OTPs
Expanded coverage to include buprenorphine-based
medication dispensing and administration. OTPs will have
a daily and weekly billing option for both methadone and
buprenorphine administration, along with coverage of the
buprenorphine medications.
Introduced peer recovery support as a covered Medicaid
service
Peer Support: Medicaid
Psychotherapy Codes
Covered entire psychotherapy code set, including family
psychotherapy.
Rates set at 146.8% of the Medicaid maximum.
Added psychological testing codes
Psychological Testing
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Policy and Coverage Outcomes
SUD Basic Benefit Package
SUD Residential
ASAM Outpatient Level of Care is available to
everyone (not subject to prior authorization;
limited only by total hours)
Per diem payments are available for SUD residential levels
of care, including withdrawal management. Providers will
no longer be required to have a psychiatrist on staff, but
will be required to have access to a psychiatrist.
Added MH day treatment hourly and per diem codes and
rates as replacements to MH partial hospitalization code
and rate
MH Day Treatment
SUD and Mental Health
Code and Rate Alignment
SUD and MH payment rates are the same for
common codes/activities (e.g., E&M, nursing,
psychotherapy)
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Policy and Coverage Outcomes
SBIRT
Specialized Recovery
Services (SRS) Program
Added Screening, Brief Intervention and Referral to
Treatment to the mental health benefit package as a
best practice
Implementing Specialized Recovery Services program for
adults identified with a SPMI – Eligibility for the SRS program
is based on the following criteria:
• Income between $743 and $2,199 per month.
• 21 years of age or older.
• Diagnosed with a severe and persistent mental illness.
• Needs help with activities such as medical
appointments, social interactions and living skills.
• Not living in a nursing facility, hospital, or similar
setting.
• Determined disabled by the Social Security
Administration.
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Next Steps
Managed care benefit
Targeted implementation January 1, 2017
Respite
Mobile Crisis and BH Urgent Care Work Group will reconvene in the fall
of 2016
Mobile Crisis and
BH Urgent Care
Work Group will reconvene in the fall of 2016
High Fidelity Wraparound
Payment Innovation
Design and implement new health care delivery payment systems to
reward the value of services, not volume.
Develop approach for introducing episode based payment for BH
services.
• Focusing on ADHD and ODD
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Next Steps - Respite
Current Medicaid Managed Care Waiver for Respite:
Overview
What is Respite?
•
"Respite services" are services that provide short-term, temporary relief to the informal unpaid caregiver
of an individual under the age of twenty-one in order to support and preserve the primary caregiving
relationship.
» The service provides general supervision of the child, and meal preparation and hands-on assistance
with personal care that are incidental to supervision of the child during the period of service delivery.
Key Provisions*
•1 Respite services can be provided on a planned or emergency basis
•2 May only be furnished in the child's home
•3 Provider must be awake during the provision of respite services
•4 Services shall not be provided overnight
*OAC 5160-26-03
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Current Provider Eligibility
After commencing service delivery, the
provider agency employee must:
Before commencing service delivery, the
provider agency employee must:
•
•
Obtain a certificate of completion of either
a competency evaluation program or a
training and competency evaluation
program, approved or conducted by the
Ohio Department of Health* or the
Medicare competency evaluation program
for home health aides**, and
•
Maintain evidence of completion of twelve
hours of in-service continuing education
within a twelve-month period, excluding
agency and program-specific orientation,
and
•
Receive supervision from an Ohio-licensed
RN and meet any other additional
supervisory requirements pursuant to the
agency's certification or accreditation***.
Obtain and maintain First Aid certification
from a class that is not solely Internetbased and that includes hands-on training
by a certified First Aid instructor, with a
successful return demonstration.
* under Section 3721.31 of the Revised Code
** as specified in 42 CFR 484.36 (October 1, 2013)
*** respite services must not be delivered by the child's legally responsible family member or foster caregiver
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Current Consumer Eligibility for Receiving Respite
To be eligible for respite services, the member must meet all of the following criteria*:
• Reside with his or her informal, unpaid primary caregiver in a home or an apartment that is not
owned, leased or controlled by a provider of any health-related treatment or support services;
• Not be residing in foster care;
• Under the age of 21 and determined eligible for social security income for children with disabilities or
supplemental security disability income;
• Enrolled in the managed care plan’s care management program;
• The member must be determined by the MCP to meet an institutional level of care;
• Requires skilled nursing or skilled rehabilitation services at least once per week;
• Received at least 14 hours per week of home health aide services for at least six consecutive months
immediately preceding the date respite services are requested, and
• The managed care plan must have determined that the child's primary caregiver has a need for
temporary relief from the care of the child as a result of the child's long term services and support
needs/disabilities, or in order to prevent the provision of institution or out-of-home placement.
Red text indicates areas of upcoming changes.
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Eligibility Criteria Under Revision
Consumer Eligibility criteria will be opened up. Criteria will include:
Those eligible for social security income for children with disabilities
or supplemental security disability income
OR…
Those meeting diagnosis and functional criteria along with
additional parameters (TBD)
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Transition Schedule
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Implementation Schedule
1/1/2017: Medicaid requires rendering
(NPI) practitioner* and/or ORP on claims
Go Live for Specialized
Recovery Services Program
Jul
Aug
Sept
7/1/2017: All providers transition to new code
set (CPTs, including E&M, along with HCPCS
codes). Medicare and NCCI** edits apply.
1/1/2017: OTP coverage updates
implemented
Oct
Nov
Dec
Jan
Feb
Mar
Apr
2017
2016
May
Jun
Jul
2017
*Practitioners who must enroll with Ohio Medicaid :
(If not one of the below, you must put agency NPI for rendering)
Physicians
Physician Assistants
Certified Nurse Practitioners
Clinical Nurse Specialists
Registered Nurses
Licensed Practical Nurses
Milestone
Licensed Independent Chemical Dependency Counselors
Licensed Independent Marriage and Family Therapists
Licensed Independent Social Workers
Licensed Professional Clinical Counselors
Licensed Psychologists
**NCCI prohibits use of nonstandard units (i.e., no more decimals)
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Timeline: 2016-2019
Transition of Care
18 months of continuity
FFS for 6
months
Ongoing planning
Jul
Oct
2016
Jan
Apr
2017
Jul
FFS PA limitations continue
under MCPs for 12 months
Oct
Jan
2018
Transition to
new code set
Apr
Jul
Oct
Jan
2019
Managed
Care Carve-In
•
Plans will abide by state prior authorization limits for one year after carve-in. Additionally,
benefit limits will be reset Jan. 1, 2018, so individuals will have 18 months of continuity under
this policy (6 months under FFS and 12 months under managed care).
•
Any prior authorizations done by Medicaid prior to carve-in will be honored by the plans, and
the plans will take over the prior authorization process when authorizations under FFS expire.
Milestone
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Children’s Residential Services
Children’s Residential Services – Current Practice
Residential Centers and Group Homes are facilities where children reside for
short or longer periods in order to receive care and supervision 24 hours a day for
two or more consecutive weeks. Most children served in these setting are
emotionally or behaviorally disturbed, medically fragile and/or require special
medical treatments due to physical conditions or diseases, or have developmental
disabilities. ODJFS and OMHAS are the primary state regulatory agencies for these
programs. *
Current and Future Funding Practices
Medicaid Services
A la carte MH services
A la carte SUD services
Room and Board
Title IV-E
Medical services
Dental services
Etc.
* Residential Centers & Group Homes. OACCA, n.d. Web.
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Services for Children Including Early Intervention
Qualifying Diagnoses
 For behavioral health services provided
to children (from birth to 21), there
will be no claims edits in MITS on
diagnosis.
 Diagnosis must be determined by a
practitioner who is authorized to
diagnose.
 Services must be medically necessary.
 Services may be subject to postpayment review.
Reminder: Recognized ICD-10 codes for behavioral health services
expanded starting July 1, 2016.
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School Psychologists
ODE Certification
Must have a Master’s Degree in School
Psychology
Education
Limited to school psychology within the scope
of employment by a board of education or by
a private school meeting the standards under
division (D) of section 3301.07 of the Revised
Code, or while acting as a school psychologist
in a program for children with disabilities
established under ORC Chapter 3323 or 5126.
Psychology Board Licensure
Must meet the following criteria: 4 years of
experience as a school psychologist (which can
include master’s program internship year), Pass
the PRAXIS exam and Pass the Ohio Board of
Psychology Oral Exam
Can practice school psychology independently
under ORC 4732.01 (E)
• Examples: Private practice, independently in
a CMHC, hospital, etc.
Scope/Location
Psychologist and
CBHC Interaction
ADDITIONALLY – School Psychologists may
work as a School Psychology Assistant, Trainee,
or Intern when working in the community
under the supervision of a Board Licensed
School Psychologist or Psychologist.
Psychologist must be registered with the
Psychology Board.
Board Licensed Independent School
Psychologist
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MH Day Treatment
MH Day Treatment Group Activities - Hourly
Rate Development and Methodology
H2012
Assumes 1 hour of unlicensed BA in an average
group size of four
H2012
Assumes 1 hour of unlicensed MA in an average
group size of four
H2012
Assumes 1 hour of licensed practitioner in an
average group size of four
$18.54
Hourly Per Person
$21.05
Hourly Per Person
$28.10
Hourly Per Person
MH Day Treatment: Additional Details
1.
2.
Maximum group size: 1:12 practitioner to client ratio
a. For MH Day Treatment, only used if the person attends for the minimum needed to bill the unit (30+
minutes). Service is billed in whole units only.
b. If person doesn’t meet the minimum, 90853 may be used for licensed practitioner or H2019 (HQ:
Modifier for group) may be used for the BA and MA.
All other services must be billed outside of H2012. H2012 can only be billed if the person attends the
minimum amount of time (30+ minutes) in a group which doesn’t exceed the practitioner to client ratio.
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MH Day Treatment Group Activities - Per Diem
Rate Development and Methodology
H2020
H2020
H2020
Assumes 5 hours of unlicensed BA providing group
counseling in an average group size of four
Assumes 5 hours of unlicensed MA providing group
counseling in an average group size of four
Assumes 5 hours of licensed practitioners providing
group counseling in an average group size of four
$104.55
Per Diem Per Person
$117.05
Per Diem Per Person
$140.51
Per Diem Per Person
MH Day Treatment: Additional Details
1.
2.
3.
4.
Maximum group size: 1:12 Practitioner to client ratio
a. For MH Day Treatment Services, only used if the person attends for the minimum needed to bill the per diem (2.5+ hours).
b. If person doesn’t meet the minimum, 90853, H2019 (HQ: Modifier for group), and/or H2012 may be used.
c.
Service is billed in whole unit only.
d. All other services must be billed outside of H2020. H2020 can only be billed if the person attends the minimum amount of
time in a group (2.5+ hours) which doesn’t exceed the practitioner to client ratio.
Only one H2020 per diem, per patient, per day
Must be nationally accredited
Must be supervised by a licensed independent practitioner
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MH Day Treatment Scenario 1
Scenario
Scenario 1: Weekly billing for 29 children, with two children in Crisis on two separate days spending 3 hours with the licensed practitioner
and 2.5 hours in Group Therapy on those days. All 29 children have at least 2 hours of Individual/Family Therapy a week and weekly
Medication Management by a nurse.
Partial Group is provided by BA-level practitioner.
• Two children in Crisis do not attend Group Therapy for 2 continuous hours, but have 2.5 hours of non-continuous Group Therapy on days
they are in Crisis.
• Pharm Management is provided to each child for 0.5 hour per week by an RN.
• Individual Therapy with licensed practitioner is separately billed. Each child receives 1 hour of Individual Therapy with a licensed
practitioner each week.
• Individual Therapy with unlicensed practitioner is not currently billed separately. Each child receives individual therapy with a BA-level
practitioner for 1 hour per week.
• CPT rates to 146.8% of the Medicaid maximum (91% of Medicare).
• *Interactive complexity may be used in accordance with CPT guidelines and supported in documentation.
Total Daily Units
Service
TBS Per Diem —
BA
Code
Fee
H2020 HN
$104.55
Unit
Per Diem
Mon.
Tues.
Wed.
Thurs.
Total Dollars
Fri.
Total
29
29
29
29
29
145
$15,159.75
Individual
Counseling (ad hoc
w/ licensed provider)
90837
$102.31
Hour
6
4
6
4
5
25
$2,557.75
*Interactive
Complexity
90785
$11.74
Per Encounter
3
1
3
1
3
11
$129.14
H2019 HN
$19.96
15 min
24
24
24
24
20
116
$2,315.36
TBS Individual —
RN (for Pharm
Management)
H2019
$27.33
15 min
12
12
12
12
10
58
$1,585.14
Crisis — Licensed
90839
$ 116.51
Hour
2
$466.04
$ 55.96
30 min
-
4
90840
-
2
Crisis — Licensed
-
16
$895.36
Individual
Counseling (ad hoc
w/ unlicensed
provider)
8
8
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MH Day Treatment Scenario 2
Scenario
• Weekly billing for 29 children, with two children in Crisis on two separate days spending 3 hours with the licensed practitioner and only
3 hours in Group Therapy on those days. All 29 children have at least one Individual/Family Therapy session a week and weekly
Medication Management by a nurse.
• Partial Group is provided by licensed practitioner.
• Two children in Crisis do not attend Group Therapy for 2 continuous hours, but have 3 hours of non-continuous Group Therapy per day.
• Pharm Management is provided to each child for 0.5 hour per week.
• Individual Therapy with licensed practitioner is separately billed. Each child receives 1 hour of Individual Therapy with a licensed
practitioner each week.
• Individual Therapy with unlicensed practitioner is not currently billed separately. Each child receives individual therapy with a BA-level
practitioner for 1 hour per week.
• CPT rates to 146.8% of the Medicaid maximum (91% of Medicare)
• *Interactive complexity may be used in accordance with CPT guidelines and supported in documentation.
Units Billed
Code
Fee
Unit
TBS Per Diem — Licensed
H2020 HK
$ 140.51
Per Diem
29
29
29
29
29
145
$ 20,373.95
Individual Counseling (ad
hoc w/ licensed provider)
90837
$ 102.31
Hour
6
4
6
4
5
25
$ 2,557.75
*Interactive Complexity
90785
$ 11.74
Per Encounter
3
1
3
1
3
11
$ 129.14
H2019 HN
$ 19.96
15 min
24
24
24
24
20
116
$ 2,315.36
H2019
$ 27.33
15 min
12
12
12
12
10
58
$1,585.14
Crisis — Licensed
90839
$ 116.51
1 hour
2
$ 466.04
$ 55.96
30 min
-
4
90840
-
2
Crisis — Licensed
-
16
$ 895.36
Individual Counseling (ad
hoc w/ unlicensed provider)
TBS Individual — RN (for
Pharm Management)
Total
Mon.
Tues.
8
Wed.
Thurs
8
Fri.
Total
Total Dollars
Service
$ 28,322.754
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Evidence-Based Practices for Mental Health
Assertive Community Treatment (ACT) –
Fidelity Measurement
Please see the printout (ACT Fidelity Rating Tool) for reference and review:
ACT Fidelity Document
ACT Fidelity Measurement
1. Fidelity Measures to
qualify for ACT billing
methodology were built
on recommendations and
discussions from
November 2015
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ACT ‘Small Team’ Monthly Billing Example
DACTS/TMACT
with MD/DO:
Code - H0040
MD/DO
Unit Rates
$662.60
$383.75
TMACT w/APRN:
Code - H0040
APRN
Master’s/RN
$282.80
Master’s/RN
Bachelor’s
$221.41
Bachelor’s
Peer Recovery
Supporter
$178.50
Peer Recovery
Supporter
Total: $1,345.31
Total: $1,066.46
Under TMACT, the team can bill an additional Bachelor’s rate for Supported Employment
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Intensive Home Based Treatment (IHBT) –
Fidelity Measurement
Please see the printout (IHBT Fidelity Rating Tool) for reference and review:
IHBT Fidelity Document
IHBT Fidelity Measurement
1. Fidelity Measures to
qualify for the IHBT billing
methodology were built
on premises similar to
ACT
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IHBT Billing Structure
Code - H2015
Master’s*
HO modifier
Unit Rate (15 minute)
$33.26
Must meet minimum fidelity requirements, 3 contacts per week.
*Medicaid will only cover when service is provided by Master’s level clinician
IHBT is a fully prior authorized service
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Managed Care Design Dimensions
Stakeholder Feedback
May and June 2015
Managed Care Design Decisions
• Ohio Revised Code 5167.04 (B)(1) [effective 9/29/2015]: “The
department shall begin to include the services in the system not
later than January 1, 2018.”
• Require MCPs to delegate components of care coordination to
qualified community behavioral health providers
Standardized Approach
• Clinical outcomes and
plan performance
measures
• Care management
identification strategy
for high risk population
• Billing and coding
methodologies
• Benefit design
Align in Principle
Differ by Design
• Real time data sharing
• Purchase services to
and use of EHR, where
enhance expertise in
possible
behavioral health
• Require value based
service
purchasing/contracting
coordination/delivery
• Utilization management • Payment strategies
strategies (e.g. prior
• Selective contracting
authorizations, forms,
process, etc.)
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Key Design Dimensions for Consideration:
Managed Care Design
Key Design Dimension
Network Adequacy
Integration
Description
•
Assure access to needed services and supports which should include
organizational contracts and access to care requirements
•
Define clear expectation for network adequacy, including measures specific to
access to services.
•
Recognize longstanding child protective services relationship with community
providers and unique needs of the client population would impact a continuum
of services, considering EPSDT requirements, psychotropic medication
management, parent treatment, and timeliness of service
•
Providers of children’s BH services, especially for seriously emotionally
disturbed kids, are a very specialized group.
•
General - Integrating physical health, behavioral health and other needed
services and supports
•
Patient education and active engagement, continuity of care and patient choice
of providers, recognition of current MHAS Certified provider’s base level
capacity, limit prior authorization to inpatient psychiatric services, partial
hospitalization, detoxification services, and recognize existing FFS payment
rates
•
Make consistent with integration of physical health care for child protective
services (CPS) population and sufficient time for CPS infrastructure and
workforce changes and training of foster kinship and adoptive parents
Timeline
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Key Design Dimensions for Consideration:
Managed Care Design
Key Design Dimension
Standardization
Quality Indicators
Funding Structure
and Revenue Cycle
Mgmt.
Description
•
Economies of scale in development of IT infrastructure, mutual data sharing,
and data analytics.
•
Define specific expectations around IT as the data element inconsistency is the
biggest driver for rising costs and variations.
•
Define the MCP Prior Authorization, Billing, Claims Processing & Payment
Requirements
•
Define unique needs relative to prior authorizations, grievances and appeals,
protocol for transportation and residential care for Child Protective Services
•
Ensure unique needs of child protection services population outcomes are met
and aligned with existing mandated measures
•
Child protective services BH indicators should not be limited to hospitalizations
but should also be ability to learn, stay out of jail, and achieve and sustain
successful community living.
•
Establish standard provider quality metrics and performance targets to be
achieved during and after transition period
•
Based on how MITS pays claims, the revenue cycle could potentially be
impacted by a large amount of money.
•
Children’s services funding should be structured to support braided funding for
child welfare, juvenile justice, education, and developmental disabilities.
•
Establish expectations for provider payment incentive models (shared and/or full
risk options). Requirements to transition to value based purchasing.
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Key Design Dimensions for Consideration:
Managed Care Design
Description
Key Design Dimension
Stakeholder
Involvement
Accountability
Care Management
•
Involve Consumers, MCPs, Providers, Boards & Others in design process
•
Plans need to be transparent in the drugs they cover and the services they
cover. There should be a way to compare plans.
•
Recognize unique needs of child protective services system for adequate
stakeholder involvement
•
Define MCP & provider roles & responsibilities
•
How will legally or judicially required services be provided for child protective
services?
•
Define care management functionality & accountability at appropriate levels
•
Delegate care management focused on integration of physical, behavioral,
social, and recovery services and supports
•
Clarify MCP role with child protection case worker, mandated duties and
provider CPST roles specifically for child protective services BH
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Key Design Dimensions for Consideration:
Managed Care Design
Description
Key Design Dimension
•
Define the credentialing process for providers of certain services
•
Establish clear understanding between stakeholders of allowed contracting
and rules/regulations behind contracting
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•
Assure adequate MCP experience and expertise with individuals who have
been diagnosed with SPMI, SMI & SUD
•
Ensure Managed Care Plans are educated to the child protective services
population unique needs, including high rates of trauma and the need for more
services sensitive to their chronic behavioral health disorders
Care Coordination
•
Define roles for care coordination and coordinated care delivery.
Data
•
Assure capacity & developing infrastructure
Outcomes
•
Focus on outcomes not process
Credentialing,
Contracting and
Experience
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Key Design Dimensions for Consideration:
Managed Care Design
Description
Key Design Dimension
Additional Services
Offered
•
Expand array of behavioral health services consistent with SAMHSA’s
description of a Good & Modern Addiction Treatment and Mental Health
System.
Target Utilization
•
Target utilization management to health outcomes and consider parity.
Medical Loss Ratio
•
Define medical loss ratio specifically for BH services – (90%).
Provider
Requirements
Client Centered
•
Identify specific MHAS certification of services, Population specific (MH,
SUD, Adult, Child), Population health approach (not just SPMI and SED),
Data reporting, outcome measures, Single point of accountability, Integrated
care planning and service delivery
•
Work towards towards achieving end-user goals (all participants in system)
•
Ensure customer is satisfied with their services as this relates directly to
effectiveness of treatment.
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Questions?
Behavioral
Health
Redesign
Website
Go To:
bh.medicaid.ohio.gov
Sign up online for the
BH Redesign Newsletter.
Go to the following OhioMHAS
webpage: http://mha.ohio.gov
/Default.aspx?tabid=154 and
use the “BH Providers Sign
Up” in the bottom right corner
to subscribe to the BH
Providers List serve.
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bh.medicaid.ohio.gov – Contact Us
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