1112017 1 Informational Webinar for Providers and Community Partners September 22 2016 Drug Medi Cal Organized Delivery System Pilot Program 2 Federal Landscape Waiver Authority Managed Care Implications ID: 769145
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1/11/2017 1 Informational Webinar for Providers and Community PartnersSeptember 22, 2016 Drug Medi -Cal Organized Delivery System Pilot Program
2 Federal Landscape Waiver Authority / Managed Care ImplicationsCore Elements of the PilotBenefitsBeneficiary Eligibility County Responsibilities Provider Considerations State Responsibilities Fiscal ProvisionsEvaluationImplementation Process Overview of Presentation
3 Marlies Perez, Division Chief, Substance Use Disorder Compliance, MHSUDS, DHCS Molly Brassil, Harbage ConsultingDon Kingdon, Harbage ConsultingRhyan Miller, Riverside County Presenters
4 ASAM: American Society of Addiction Medicine DMC: Drug Medi-Cal CPE: Certified Public Expenditure FFP: Federal Financial Participation IMD: Institution for Mental Disease IOT: Intensive Outpatient Treatment MAT: Medication Assisted Treatment NTP: Narcotic Treatment Programs ODS: Organized Delivery System SUD: Substance Use Disorder TAR: Treatment Authorization Request Acronym Key
5 CMS Guidance. 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 SUDs.1115 Waiver Opportunity. Includes a new section 1115 waiver opportunity to build a robust continuum of care for beneficiaries with SUDs. Short-Term IMD Services. 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). CA as Trailblazer. California is the first 1115 project approved under this guidance. Federal Landscape
6 Component of Larger 1115 Waiver. The DMC-ODS Pilot Program is authorized and financed under the authority of the state’s Medi-Cal 2020 Waiver.Elective for Counties. The DMC-ODS Pilot Program will be elective for 5 years.Standard Terms & Conditions. Outline of requirements for eligibility, benefits, county responsibilities, state oversight, and reimbursement. California Waiver Authority
7 Managed Care. Under managed care, beneficiaries receive part, or all, of their Medicaid services from providers who are paid by an organization (i.e. county) that is under contract with the State. DMC Pilot Counties as Managed Care Plans. Counties participating in the DMC-ODS Pilot Program will be considered managed care plans.Prepaid Inpatient Health Plan. Upon approval of the implementation plan, the State shall enter into an intergovernmental agreement with the County to provide or arrange for the provision of DMC-ODS pilot services through a “Prepaid Inpatient Health Plan” (PIHP), as defined in federal law. Federal Managed Care Requirements. Accordingly, DMC-ODS Pilot PIHPs must comply with federal managed care requirements (with some exceptions). DMC-ODS Managed Care
8 Benefits. Continuum of care modeled after nationally-recognized standard of care (ASAM) Accountability. Increased local control and accountabilityBeneficiary Protections. Strong provisions for program integrity and beneficiary protectionsOversight. Utilization tools to improve care and manage resources Quality. Evidence-based practicesIntegration. Coordination with other systems of care Core Elements of the Pilot Program
9 ASAM Continuum. Continuum of care modeled after nationally-recognized standard of care (ASAM).Pilot Benefits. Beneficiaries that reside in a Pilot county receive expanded DMC-ODS benefits. Eligibility for Pilot services is based on the MEDS file.Standard (State Plan) Benefits. Standard DMC services will be available to beneficiaries in all counties. Access to State Plan services must remain at the current level or expand upon implementation of the pilot. Non-Pilot Counties. In counties that do not opt in, beneficiaries receive only those SUD treatment services outlined in the approved state plan. Benefits
10 Standard DMC Benefits (available to beneficiaries in all counties ) Pilot Benefits (only available to beneficiaries in pilot counties ) Outpatient Drug Free Treatment Outpatient Services Intensive Outpatient Treatment Intensive Outpatient Services Naltrexone Treatment (oral for opioid dependence or with TAR for other) Naltrexone Treatment (oral for opioid dependence or with TAR for other) Narcotic Treatment Program (methadone) Narcotic Treatment Program (methadone + additional medications) Perinatal Residential SUD Services (limited by IMD exclusion) Residential Services (not restricted by IMD exclusion or limited to perinatal) Detoxification in a Hospital (with a TAR) Withdrawal Management (at least one level) Recovery Services Case Management Physician Consultation Partial Hospitalization (optional) Additional Medication Assisted Treatment (optional) Drug Medi -Cal Benefits
11 Standard Residential (non-ODS) Residential Under DMC-ODS Pilot State plan currently limits residential SUD services to perinatal beneficiaries only. Services are provided to non-perinatal and perinatal beneficiaries (all eligible adults and adolescents). Federal matching funds are only available for services provided in facilities not considered IMDs (i.e. 16 bed max). No bed capacity limit (i.e. 16 bed IMD exclusion does not apply) Providers must be designated by DHCS to meet ASAM treatment criteria Counties must provide prior authorization for residential services within 24 hours of submission of the request. Residential Treatment
12 Standard Residential (non-ODS) Residential under DMC-ODS Pilot State plan currently limits residential SUD services to perinatal beneficiaries only. Services are provided to non-perinatal and perinatal beneficiaries (all eligible adults and adolescents). Federal matching funds are only available for services provided in facilities not considered IMDs (i.e. 16 bed max). No bed capacity limit (i.e. 16 bed IMD exclusion does not apply) Providers must be designated by DHCS to meet ASAM treatment criteria Counties must provide prior authorization for residential services within 24 hours of submission of the request. Medication Assisted Treatment
Drug Medi -Cal Organized Delivery Service - Medication Assisted Treatment 13
14 No age restrictionsEligibility: Enrolled in Medi-CalReside in Participating CountyMeet Medical Necessity Criteria: Adults : One DSM Diagnosis for substance-related and addictive disorders (with the exception of tobacco); meet ASAM criteria definition of medical necessity for services Children: Be assessed to be at risk for developing a SUD and meet the ASAM adolescent treatment criteria (if applicable) Beneficiary Eligibility
15 County Responsibilities
16 Accessible Services. Each county must ensure that all required services covered under the pilot are available and accessible to enrollees. Out of Network Coverage. If the county is unable to provide services, the county must adequately and timely cover these services out-of-network for as long as the county is unable to provide them. Appropriate and Adequate Network. The county shall maintain and monitor a network of appropriate providers that is supported by contracts with subcontractors, and sufficient to provide adequate access. Provider Selection. Access cannot be limited in any way when counties select providers. Timely Access. Hours of operation are no less than those offered to commercial enrollees or comparable Medi -Cal FFS, if the provider only services Medi -Cal. Includes 24/7 access, when medically necessary. Cultural Considerations. Pilot county participates in the State’s efforts to promote the delivery of services in a culturally competent manner to all enrollees, including LEP and diverse cultural / ethnic backgrounds. Monitoring. Monitor providers regularly to determine compliance and take corrective action if there is a failure to comply. Access
17 In establishing and monitoring a network, pilot counties must consider: Timely Access Standards. Ability of providers to meet Department standards for timely access to care and services as specified in the county implementation plan and contract.Emergency and Crisis Care. Ability to assure that medical attention for emergency and crisis medical conditions be provided immediately. Number of Eligibles. The anticipated number of Medi -Cal eligible clients. Utilization. The expected utilization of services, taking into account the characteristics and SUD needs of beneficiaries. Number / Type of Providers. The expected utilization of services, taking into account the characteristics and SUD needs of beneficiaries. Providers Not Accepting New Patients. The number of network providers who are not accepting new beneficiaries.Geography. The geographic location of providers and their accessibility to beneficiaries, considering:Distance Travel Time Means of Transportation Ordinarily Used by Medi -Cal Beneficiaries Physical Access for Disabled Beneficiaries Network Adequacy
18 Policies and Procedures. County should have written policy and procedures for selection and retention of providers that are applied equallyCriteria. Counties will only select providers that have:A license and/or certification in good standing Enrolled / revalidated enrollment with DHCS as a DMC provider and have been screened as a “high” categorical risk A medical director who has enrolled with DHCS, has been screened as a “limited” categorical risk within a year prior, and has a signed Medicaid provider agreement with DHCS Contracting. Counties must enter into contracts with selected providers Selective Provider Contracting – Selection Criteria
19 Pilot counties must include the following requirements in their provider contracts: Cultural Competency. Provide culturally competent services, including translation services, as needed.Coordination. Procedures for coordination of care for enrollees receiving Medication Assisted Treatment (MAT) services. EBPs. Implement at least two (2) of the following Evidence Based Practices (EBPs): Motivational InterviewingCognitive-Behavioral Therapy Relapse Prevention Trauma-Informed Treatment Psycho-Education Selective Provider Contracting – Provider Contract Requirements
20 Written Notification of Denial. County must serve providers that are not selected with a written decision and have a protest procedure for providers that are not selected. Local Protest Procedure. Providers may challenge the denial to DHCS only after the local protest procedure has been exhausted; must also have reason to believe that the county has an inadequate networkState Appeal. Following submission of appeal and county response, DHCS will set a date for parties to discuss with a DHCS representative with subject matter knowledge. Final Determination. DHCS will make a final determination, which may result in no further action or a county corrective action plan (CAP). Selective Provider Contracting – Contract Denial / Appeal Process
21 Professional staff must be licensed, registered, certified, or recognized under California scope of practice laws. Licensed Practitioner of the Healing Arts (LPHA) includes:PhysicianNurse PractitionerPhysician Assistant Registered Nurses Registered Pharmacists Licensed Clinical Social Worker (LCSW)Licensed Clinical Psychologist (LCP)Licensed Professional Clinical Counselor (LPCC) Licensed Marriage and Family Therapist (LMFT) License-eligible practitioners working under the supervision of licensed clinicians Provider Specifications
22 Registered and certified alcohol and other drug counselors Must adhere to all requirements in the CCR, Title 9, Chapter 8 Non-professional staff Must be supervised and receive on-site training. Provider Specifications Cont.
23 Provider Certification. The DHCS Provider Enrollment Division (PED) is responsible for the enrollment and re‑enrollment of fee-for-service (FFS) health care service providers into the Medi-Cal program. DHCS PED Website: http://www.dhcs.ca.gov/provgovpart/Pages/PED.aspx Provider Enrollment
24 State Responsibilities
25 Certified Public Expenditure. Counties will certify the total allowable expenditures incurred in providing DMC-ODS pilot services through county-operated or contracted providers. County-Specific Rates. Counties will develop proposed county-specific interim rates for each covered service (except for NTP) subject to state approval. 2011 Realignment Provisions / BH Subaccount. 2011 Realignment requirements related to the BH Subaccount will remain in place and the state will continue to assess and monitor county expenditures for the realigned programs. Fiscal Provisions
26 Federal Financial Participation (FFP). FFP will be available to contracting pilot counties who certify the total allowable expenditures incurred in delivering covered services. County-Operated Providers. County-operated providers will be reimbursed based on actual costs.Subcontracted Providers. Subcontracted fee-for-service providers will be reimbursed based on actual expenditures. CPE Protocol. Approved by CMS to allow FFP under the Pilot. Includes provisions related to: Inflation FactorLower of Cost or Charge Cost Report Fiscal Provisions Cont.
27 Annual Fiscal Plan. Counties are required to complete and submit an Annual County Fiscal Plan following DHCS guidance.DHCS Review and Approval. DHCS will review and approve the plan annually.Interim Rates. Proposed interim rates must be developed for each required and selected optional service specified in the waiver. Supporting Information . Counties must provide supporting information consistent with state and federal guidance for each proposed rate. Sources. Appropriate sources of information include filed cost reports, approved medical inflation factors, detailed provider direct and indirect service cost estimates, and verified charges made to other third party payers for similar programs. Fiscal Provisions: Fiscal Plan
28 Residential Rates. Proposed residential rates must include clear differentiation between treatment and non-treatment room and board costs. Outpatient Rates. Proposed outpatient treatment rates should include all assessment, treatment planning and treatment provision direct and indirect costs consistent with coverage and program requirements outlined in state and federal guidance. Admin, QI, UR, etc. County administrative, quality improvement, authorization, and utilization review activities may be claimed separately consistent with state and federal guidance. Fiscal Provisions: Fiscal Plan Cont.
29 University of California, Los Angeles (UCLA) Integrated Substance Abuse Programs will conduct the evaluation. Four key areas:AccessQualityCostIntegration and Coordination of Care Evaluation
30 Phase I – Bay Area (May 2015)Phase II – Southern California (Nov 2015) Phase III – Central Valley (March 2016)Phase IV – Northern California (November 2016)Phase V – Tribal Delivery System (TBD 2017) Implementation Phases
DMC-ODS Implementation Matrix DMC-ODS Implementation Matrix
DMC-ODS Implementation Matrix (Cont.) DMC-ODS Implementation Matrix (Cont.)
33 Implementation Plan: Counties receive preliminary approval from DHCS on their DMC-ODS Implementation Plan. Interim Rates: Counties receive DHCS approval of the fiscal plan and interim rates.County-Specific Contract: DHCS will generate the county-specific contract, incorporating content from the Implementation Plan and approved interim rates. Approval from Board of Supervisors: Counties will obtain approval of the county-specific contracts from their Board of Supervisors. Approval from CMS: After the contract is approved by the Board of Supervisors, CMS will approve the contract and issue a formal letter of approval to DHCS. List of County Contracted Providers: Counties must submit this to DHCS within 30-days of the DMC/ODS waiver implementation date. Beneficiary Informing Materials: Beneficiary informing materials must be available at all DMC/ODS provider sites and must be provided to beneficiaries at initial contact. Grievances and Appeals: Beneficiary protection and appeal procedures and Notices of Action(NOA) must be in place for all DMC/ODS enrolled beneficiaries and providers.MOU(s): Counties must have executed MOU(s) with Medi -Cal managed care plan(s) at the time of implementation OR an explanation and timeline as to when MOU(s) will be executed. County Implementation Checklist
34 For questions, please contact dmcodswaiver@dhcs.ca.gov For additional information, please see the DMC-ODS Frequently Asked Questions posted the DHCS website: http://www.dhcs.ca.gov/provgovpart/Pages/FAQs_Fact_Sheets.aspx Contact and Resources
35 Karen Baylor, PhD, Deputy Director, MHSUDS, DHCSMarlies Perez, Division Chief, MHSUDS, DHCS Don Braeger , Division Chief, MHSUDS, DHCS For More Information: http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx California Department of Health Care Services
Harbage Consulting Don Kingdon, PhD, Principal, Behavioral Health Integration don@harbageconsulting.com Molly Brassil, MSW, Director, Behavioral Health Integration molly@harbageconsulting.com Courtney Kashiwagi, MPH, Senior Consultant courtney@harbageconsulting.com Erynne Jones, MPH, Senior Consultant erynne@harbageconsulting.com 36