Coordinating Access to Residential Behavioral Health Services for Children

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1 Coordinating Access to Residential Behavioral Health Services for Children Shevaun Harris Chief, Bureau Medicaid Policy Agency for Health Care Administration May 22, 2015

2 Objectives Provide an overview of the Managed Medical Assistance (MMA) component of the Statewide Medicaid Managed Care (SMMC) program, including updates since the implementation (enrollment statistics, complaint summary, etc.) Describe how coordination of care and payment for residential behavioral health services should work under the MMA program, including a discussion of the role of each respective entity (managed care plans, AHCA, DCF, managing entities, etc.) in the process. Provide information on how the Guardian ad Litem (GAL) program and other stakeholders can alert the Agency and managed care plans promptly of any difficulties in securing treatment services for children who need residential behavioral health services. 2

3 Overview & Updates Managed Medical Assistance (MMA) 3

4 The Statewide Medicaid Managed Care (SMMC) Program The program has two components: the Long-Term Care (LTC) program and the Managed Medical Assistance (MMA) program. MMA covers most recipients of any age who are eligible to receive full Medicaid benefits. LTC covers most recipients 18 years of age or older who need nursing facility level of care. This presentation will mainly focus on the MMA component of the SMMC program. 4

5 SMMC Program The Agency for Health Care Administration completed the implementation of the Statewide Medicaid Managed Care program in August 2014, and the majority of Medicaid recipients are now receiving their services through managed care plans. Managed care plans are required to cover the majority of medical, behavioral, and dental services covered under the Florida Medicaid program, this includes residential treatment services that were previously not covered under managed care. 5

6 SMMC Program Goals The goals of the Statewide Medicaid Managed Care Program are: To improve coordination of care Improve the health of recipients, not just paying claims when people are sick Enhance accountability Allow recipients a choice of plans and benefit packages Allow plans the flexibility to offer services not otherwise covered Enhance prevention of fraud and abuse through contract requirements. 6

7 SMMC Program Elements Plan Choice HMOs and PSNs (provider service networks) Specialty Plans in MMA Choice of Benefit Package Choice Counseling Risk Adjusted Rates 7

8 SMMC Program Enhancements: Network Adequacy Standards Time and distance standards Ratios of patients to providers Increasing the number of primary care and specialist providers accepting new Medicaid enrollees Increasing the number of primary care providers that offer appointments after normal business hours Extremely low level of complaints/issues. 8

9 SMMC Program Enhancements: Network Adequacy Standards, cont. Managed Medical Assistance Provider Network Standards Table Urban County Rural County Regional Provider Ratios Required Providers Maximum Time (minutes) Maximum Distance (miles) Maximum Time (minutes) Maximum Distance (miles) Providers per Recipient Primary Care Providers :1,500 enrollees Specialists Adolescent Medicine :31,200 enrollees Cardiology (Pediatrics) :16,667 enrollees Endocrinology (Pediatrics) :20,000 enrollees Nephrology (Pediatrics) :39,600 enrollees Neurology (Pediatrics) :22,800 enrollees Pediatrics :1,500 enrollees Therapist (Occupational) :1,500 enrollees Therapist (Speech) :1,500 enrollees Therapist (Physical) :1,500 enrollees Therapist (Respiratory) :8,600 enrollees 9

10 Standard Plans Only Managed Medical Assistance services, or Only Long-term Care services SMMC Structure Comprehensive Plans Cover all Long-term Care and Managed Medical Assistance services. Plan care coordinator(s) coordinates with all of the recipient s medical and long-term care providers. Specialty Plans Cover Managed Medical Assistance services. Plans serve Medicaid recipients who meet specified criteria based on: age condition, or diagnosis 10

11 Selecting SMMC Plans Health plan contracts were competitively procured in each of 11 regions. The Agency received bids and awarded contracts to HMOs and Provider Service Networks (PSNs). Contracts are for a five-year contract period. 11

12 MMA Program The MMA program provides primary care, acute care and behavioral health care services to recipients eligible for enrollment. Most Medicaid recipients are required to enroll in an MMA plan, with the exception of: Individuals eligible for emergency services only due to immigration status Medically Needy individuals Family planning waiver eligibles Women eligible through the breast and cervical cancer program. 12

13 MMA Provider Networks Managed Medical Assistance plans may limit the providers in their networks based on credentials, quality indicators, and price, but they must include the following statewide essential providers: MMA Program Required Essential Network Providers Faculty Plans of Florida Medical Schools Specialty Children s Hospitals Regional Perinatal Intensive Care Centers (RPICCS) Health Care Providers serving Medically Complex Children, as determined by the State. 13

14 Advantages Comprehensive Plans Comprehensive plans cover all LTC and MMA services. Increased ability of the managed care plan to coordinate care. The plan is responsible for most Medicaid services. Plan care coordinator(s) coordinates with all of the recipient s medical and long-term care providers. 14

15 MMA Specialty Health Plans A specialty plan is a managed care plan that serves Medicaid recipients who meet specified criteria based on age, medical condition, or diagnosis. When a specialty plan is available to accommodate a specific condition or diagnosis of a recipient, the Agency will assign the recipient to that plan. Recipients can always choose to enroll in a standard MMA plan, even if they are eligible for specialty plan enrollment. MMA Specialty Plans are required to cover the same standard services available in the non-specialty plans and must meet provider network standards outlined for standard plans. 15

16 MMA Specialty Health Plans Each specialty plan provides an Agency-approved care coordination/case management program specific to the specialty population. Specialty plans may offer additional expanded benefits and may report on additional performance measures. Specialty plans may have enhanced provider network standards. 16

17 If a recipient qualifies for enrollment in more than one of the available specialty plan types, and does not make a voluntary plan choice, they will be assigned to the plan for which they qualify that appears highest in the chart below: Child Welfare specialty plan Children s Medical Services Network HIV/AIDS Serious Mental Illness Freedom Health specialty plans 17

18 Specialty plans Expanded Benefits All managed care plans participating in the SMMC program have the opportunity to offer expanded benefits to their enrollees. Expanded benefits are services that are offered in addition to those available through the Medicaid program. Plans can: Exceed the limits stated in Medicaid policy for certain services; or Offer additional services not covered under the Medicaid state plan (e.g., art therapy, post discharge meals, etc.). Specialty plans can choose to offer expanded benefits tailored to their unique population. 18

19 Specialty plans Expanded Benefits Child Welfare HIV/AIDS (Clear Health) HIV/AIDS (Positive) SMI Adult dental services (Expanded) Adult hearing services (Expanded) Adult vision services (Expanded) Art therapy Home and community-based services Home health care for non-pregnant adults (Expanded) Influenza vaccine Medically related lodging & food Intensive Outpatient Therapy Newborn circumcisions Nutritional counseling Outpatient hospital services (Expanded) Over the counter medication and supplies Physician home visits Pneumonia vaccine Post-discharge meals Prenatal/Perinatal visits (Expanded) Primary care visits for non-pregnant adults (Expanded) Shingles vaccine Waived co-payments NOTE: Details regarding scope of covered benefit may vary by managed care plan. CMS Network Specialty Plan (CMSN) and the specialty plan for dual eligibles with chronic conditions do not offer Expanded Benefits. 19

20

21 MMA: Standard & Comprehensive Plans Amerigroup x x x c Better Health x x Coventry c Humana x x x c c Integral x x x Molina x x x c Preferred x Prestige x x x x x x x x SFCCN x Simply x Sunshine c c c c c c c c c c United Health Care c c c c Staywell x x x x x x x x c= comprehensive plan 21

22 MMA: Specialty Plans Children s Medical Services Network/ Children with Special Health Care needs Clear Health Alliance / HIV/AIDS Freedom Health, Inc./Chronic Duals Magellan Complete Care/Serious Mental Illness Positive Healthcare Florida/HIV/AIDS Sunshine Health Plan, Inc./ Child Welfare x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x 22

23 MMA Enrollment MMA Program: 2,962,452 recipients enrolled in MMA plans as of April 1,

24 Statewide MMA enrollment by plan as of April 1, % 2% 2% 1% 1% 1% 0% 1% 0% 0% Staywell Sunshine State Amerigroup 3% 3% 23% Prestige Humana United Healthcare 5% Molina Better Health Integral 9% 14% Simply Healthcare CMSN Coventry 10% 10% 11% SFCCN Magellan (S) Preferred Medical Snshn Hlth Chld (S) Clear Hlth All (S) Source: AHCA-Comprehensive Medicaid Managed Care Enrollment Reports, April 1,

25 Statewide MMA Enrollment Standard Plan Vs. Specialty Plan as of April 1, % Specialty Plans Standard Plans 95% Source: AHCA-Comprehensive Medicaid Managed Care Enrollment Reports, April 1,

26 Enrollment by Specialty Plan as April % 1% 0% 16% 30% 46% CMSN Magellan (S) Snshn Hlth Chld (S) Clear Hlth All (S) AHF / Positive (S) Freedom Health (S) Source: AHCA-Comprehensive Medicaid Managed Care Enrollment Reports, April 1,

27 Statewide MMA Enrollment Standard Plans 2% 1% 1% 3% 3% 3% 24% Staywell Sunshine State 6% Amerigroup Prestige Humana 9% United Healthcare Molina Better Health 14% Integral Simply Healthcare 11% Coventry SFCCN Preferred Medical 11% 12% Source: AHCA-Comprehensive Medicaid Managed Care Enrollment Reports, April 1,

28 Next Steps: Report Cards Enrollees will soon be able to choose plans based upon quality. In the early part of 2015, Medicaid will begin publishing a consumer-focused Medicaid health plan report card. The report card will include ratings on how Florida s managed care plans are doing on getting children into well-child visits and to dental care. 28

29 Next Steps: Encounter Data Encounter data are electronic records of services provided to Medicaid enrollees by a capitated health plan. Encounter data are submitted in a federally-mandated HIPAAcompliant format from health plans to the Florida Medicaid Management Information System. The Agency has collected encounter data since 2008, but the data will be used more prominently in the SMMC program. 29

30 Next Steps: Encounter Data, cont. The Agency will use encounter data for three primary purposes: Transparency: Information from encounter data will be available to external stakeholders. Performance and Quality: Monitoring plans on a variety of metrics to ensure performance and quality measures are being met. Rate Setting: Encounter data will be critical in setting appropriate plan reimbursement levels. 30

31 Next Steps: Encounter Data, cont. Possible performance measures: Diabetes Short-Term Complications Admission Rate Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate Heart Failure Admission Rate Asthma in Younger Adults Admission Rate 31

32 Coordination of Care & Residential Behavioral Health Services 32

33 Residential Placement Responsibilities Children are placed by the Department of Children and Families (DCF) or their designated Community Based Care (CBC) organization. Children placed by the department and funded in full or in part by state, Medicaid, or local matching funds shall be admitted only after they have on recommendation of the appropriate multidisciplinary team, been personally examined and assessed for suitability for residential treatment. (Rule 65-E9.008(4), Fla. Admin. Code) 33

34 Residential Treatment Responsibilities Medicaid managed care plans or their subcontractor must have a process to participate in interagency staffings or school staffings that may result in the provision of behavioral health services to an enrolled child/adolescent. The managed care plan or their subcontractor must participate in such staffings upon request. AHCA Contract: Attachment II, Exhibit II-A, Section V.A.1.a.(4).(d).(iii). 34

35 Residential Treatment Responsibilities, cont. Managed care plans are responsible for recruiting and contracting with qualified providers of Therapeutic Group Care (TGC) and Statewide Inpatient Psychiatric Program (SIPP) services. Plans are required to enter into contracts with a sufficient number of providers to deliver all covered services to enrollees and ensure that each covered service is provided promptly and is reasonably accessible. 35

36 Residential Treatment Responsibilities, cont. Managed care plans develop their own utilization review process for service authorization. Managed care plans are required to maintain a provider complaint system allowing providers to dispute any aspect of the plans administrative functions, including claims. 36

37 Residential Treatment Responsibilities, cont. Managed care plans are required to respond to standard authorization requests as expeditiously as the enrollee s health condition requires and within no more than seven (7) days and expedited requests within 48 hours. Managed care plans must notify providers and give the enrollee written notice of any decision to deny a service authorization request, or to authorize a service in an amount, duration or scope that is less than requested. 37

38 Mental Health Services in a System of Care Screening/Assessment Wraparound In Home Residential School Based Respite Crisis 38

39 Indications that Out-of-Home Treatment is Appropriate Services and supports have been tried in less restrictive settings. The child or youth has a significant mental health and/or co-occurring mental health and substance abuse disorder that significantly impairs their ability to function in the community. Youth s mental health condition has a high level of acuity (i.e., multiple Baker Act admissions in a short period of time). 39

40 Definition for Severe Emotional Disturbance Child or adolescent who has serious emotional disturbance or mental illness means a person under 18 years of age who: Is diagnosed with a mental, emotional, or behavioral disorder per the DSM Exhibits behaviors that substantially interfere with or limit his or her role or ability to function in the family, school, or community, when behaviors are not considered to be a temporary response to a stressful situation. (s , F.S.) 40

41 Criteria for Referral for Therapeutic Group Care and Statewide Inpatient Psychiatric Program Services Before a dependent child can be referred for a suitability assessment, the Community Based Care Lead Agency Service Worker will review the child s current condition: Does the child have an emotional disturbance that requires the intensity and restrictiveness of treatment offered in a residential treatment center? 41

42 Access to Care for Dependent Children When the Department of Children and Families (DCF) or the Community Based Care (CBC) believes a child in custody is emotionally disturbed and may need residential treatment, an examination and suitability assessment must be conducted before placement of the child (6)(b). 42

43 Access to Care for Dependent Children Provides criteria for placement of children in Department s legal custody Outlines steps to achieve placement in a residential treatment center Provides for regularly scheduled reviews by treatment center, community based care lead agency, and the courts Section (5) F.S. 43

44 Qualified Evaluator The suitability assessment must be conducted by a qualified evaluator who is appointed by the Agency for Health Care Administration. A qualified evaluator must: Be a psychiatrist or psychologist licensed in Florida. Have at least 3 years experience in the diagnosis and treatment of serious emotional disturbances in children and adolescents; and Have no actual or perceived conflict of interest with an inpatient facility or residential treatment center or program. 44

45 The Suitability Assessment Suitable for residential treatment or suitability means a determination concerning a child or adolescent with an emotional disturbance (as defined in (5)) or serious emotional disturbance (as defined in (6)) that each of the following criteria is met: The child requires residential treatment The child is in need of a residential treatment program and is expected to benefit from mental health treatment, and An appropriate, less restrictive alternative to residential treatment is unavailable. 45

46 Suitability Assessment Recommendations The Qualified Evaluator must specify one of the following: Inpatient Residential Residential Therapeutic Group Home Residential Not Recommended. 46

47 Overview of the Pre-Admission Process 1 Multidisciplinary Team Staffing 2 Assessment of Suitability 3 Court Hearing 4 Referral for Residential Services 5 Authorization 47

48 What Happens When Residential Treatment Is Not Recommended The multidisciplinary team reconvenes and discusses community-based supports and services for the child or youth. The court has the authority to order the residential treatment of a dependent child in the custody of the department despite a contrary recommendation by the AHCA designated qualified evaluator if it affords the child the additional protections of the Baker Act. (Lee, Michael, and Traphofner, John. Memo to Mary Cagle, State Director of Children s Legal Services, Tallahassee, FL. March 2010.) 48

49 Discharge Planning Discharge Criteria for Residential Treatment: The recipient has received maximum benefit from his or her present plan of care. The recipient has not benefitted from a reasonable course of treatment. 49

50 Discharge Planning, cont. Discharge Criteria for Residential Treatment: A discharge plan had been established, and the aftercare services plan includes family or family surrogate and the district mental health office; or Severe medical problems have arisen that cannot be managed by the facility. The discharge plan must be provided to the parent, legal guardian, guardian ad-litem, and DCF at least 30 days before the proposed discharge date. (65E-9.011) 50

51 Discharge Planning, cont. Standards of Good Care: Discharge placement is identified at admission. CBC and the managed care plan are kept informed & participate in discharge planning from the time of admission. The child is given opportunities to practice skills with family at home as part of discharge planning (e.g., therapeutic passes). Appropriate referrals are made for follow-up treatment (continuity of treatment). 51

52 Discharge Planning, cont. Standards of Good Care: Clinical aftercare recommendations specify the level of structure and supervision needed by the child and what services and supports are necessary to address specified issues. Discharges occurs when child is ready to return safely to the community and continue active treatment in a less restrictive setting. Child or adolescent is assisted in working through termination process following demonstration of ability to self-manage and achievement of other treatment goals. 52

53 Assistance from GALs & Other Stakeholders 53

54 SMMC Complaints/Issues Resolution Center The Agency actively encourages recipients, providers and other stakeholders to report SMMC issues. Tracking reported issues has allowed the Agency to: Identify trends Identify possible issues with specific SMMC plans, and Have an additional tool to take action to correct these issues. All allegations and issues are recorded, regardless of whether they are found to be accurate or substantiated. 54

55 Complaint Hub The Complaint Hub manage: intake resolution tracking of all complaints related to the Statewide Medicaid Managed Care program. The hub is utilized by providers, stakeholders and recipients to request assistance with managed care issues and complaints. 55

56 Typical Complaint Sources Medicaid recipients Healthcare providers Family member or authorized representative State agency (for example: DOEA, AHCA, DCF) Advocacy groups Legislative members or staff 56

57 Examples of Complaints Request for additional services Complaint about Medicaid Managed Care services Quality of service issue Reduction/ denial of services Desired provider not in the network Coverage/ limitations Continuum of care 57

58 Process Each complaint is assigned to an AHCA complaint staff, who contacts the Managed Care Plan, and works with the complainant (i.e., recipient/caregiver/case manager/provider) and the Plan until the issue is resolved. Daily, weekly and monthly, the Hub produces a variety of reports which are shared with AHCA Leadership, AHCA Contract Management, Federal CMMS and the Managed Care Plans. Summary complaint trend analysis, by Plan and Issue Type, and timeliness of complaint resolutions are compiled and used to identify areas of possible program improvement. If a Plan is determined to be noncompliant with Agency requirements, liquidated damages may be assessed. 58

59 The MMA Program Issues Summary Report The summary reports by plan types: number of MMA enrollees as of the end of the reporting month number of issues received in the last 3 months number of issues for the reporting month number of issues, per 1,000 enrollees per the reporting month difference per 1,000 (last month compared to last 3 months), these are monthly averages median days for resolution for beneficiary and provider issues and the number resolved number of issues resolved for the reporting month, and number of issues pending for resolution for the reporting month 59

60 MMA Monthly Summary Report (March, 2015) 60

61 Managed Medical Assistance (MMA) Issues reported to the AHCA SMMC Complaint Center, since MMA Implementation (through March, 2015) Top 5 All MMA Issue Types 1. Claims Provider Payment 2. Services Continuity of Care / missed services 3. Services Problem Obtaining Authorization 4. Customer Service General 5. Services Desired Provider Not in Network Top 5 Behavioral Health Issue Types 1. Claims Provider Payment 2. Customer Service Provider Enrollment 3. Services Problem Obtaining Authorization 4. Customer Service General 5. Services Continuity of Care / missed services 61

62 Breakdown of Behavioral Health Issues Statewide 90% of Issues have been reported by Providers 89% of Issues Pertained to Children 11% 10% 90% Provider Recipient 89% Child Adult Age extrapolated from 10% sample Behavioral Health Issues: Included in these totals are any issues reported by providers or recipients, that include any reference to Behavioral Health services. These totals also include SIPP and Psychiatric services. Note - The Agency has actively encouraged all stakeholders to surface any potential issue, concern, or complaint regarding the SMMC Program to the SMMC Complaint Operations Center. All allegations and issues have been recorded, regardless of whether they were found to be accurate or substantiated. 62

63 How to Report a Complaint? If you have a complaint or issue about Medicaid Managed Care services, please complete the online form at: Click on the Report a Complaint blue button. 63

64 64

65 65

66 Filling out the Complaint Form Your name, , and phone number are requested in case more information is needed to resolve your issue. If you wish to remain anonymous, you may omit this information. If you choose to send an issue anonymously, please provide as much detail as possible. Without enough detail, we may not be able to resolve your issue; however, your input is important and will be used to improve the program. You can submit the complaint form on behalf of yourself or on behalf of another. 66

67 Filling out the Complaint Form Under Florida law, addresses are public records. If you do not want your address released in response to a public-records request, do not send electronic mail to this entity. Instead, contact the Agency by phone at or in writing. If you need assistance completing this form or wish to verbally report your issue, please call the Medicaid Help Line at (8:00 a.m. ET - 5:00 p.m. ET Monday - Friday). 67

68 Who Will Respond to my Complaint/issue? Once a complaint or issue is submitted online to the Agency s complaint/issue center, one of the Agency staff will contact the complainant. Agency staff will contact a complainant within one business day of submitting a critical or high priority complaint. 68

69 QUESTIONS? Thank you for your attendance and for the services you provide to Medicaid recipients.

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