Community Technical Assistance Center Medicaid Managed Care (MMC) Readiness Assessment Tool OCFS Voluntary Agencies February 2015

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1 Community Technical Assistance Center Medicaid Managed Care (MMC) Readiness Assessment Tool OCFS Voluntary Agencies February 2015 As of January 2016, Medicaid services for eligible children will be administered by Managed Care Organizations (MCOs). MCOs contract with NYSDOH to meet the health care needs of people with Medicaid. MCOs choose a group of health care providers to help them meet the needs of their members. These health care providers include doctors and specialists, hospitals, labs and other health care facilities that make up the MCO s provider network. Many foster care providers will also work with Health Homes (HHs) for children determined to be Health Home-eligible; some may become downstream Health Home care managers for the children they serve. Provider agencies that have historically offered services funded by Medicaid and regulated directly by NYS offices will now be reporting to MCOs with respect to the provision, quality and outcome of Medicaid-funded services. Some voluntary foster care agencies that are currently providing onsite primary health services have determined that those services will now be provided in the community; some intend to continue providing those services; and some have not yet decided. Therefore, providers previously accustomed to dealing with government agencies and ratebased methodologies will need to develop new approaches to business functions and to clinical operations. They will need to respond to the expectations and practices of a new system. The readiness assessment that follows is intended to assist providers to inventory current practices and re-design operations so that they will serve clients effectively, while preserving organizational integrity under Medicaid Managed Care. When completed, the self-assessment tool offers a snapshot of the organization s current level of readiness as well as an assessment of the need for technical assistance. This includes whether the agency s current infrastructure (IT, billing software, EHR, personnel) will meet the requirements of MCOs and Health Homes. It is strongly suggested that an agency bring its leadership team together and respond to the series of statements collectively. The discussion will not only assure that the answers are an accurate reflection of Managed Care readiness, but may also represent the beginning of your planning process to address any opportunities to increase readiness identified during the conversation. Voluntary foster care agencies should note that this survey must be completed in order to be eligible to receive a distribution of Managed Care grants that will be made available (subject to approval of the Executive Budget) in Please see the February 5, 2015 letter regarding managed care readiness activities for voluntary foster care agencies for additional Page 1 of 17

2 information. Agencies should plan to submit their completed survey electronically by March 13, Please complete the below form using the following information as a template: Broader Agency Name: ICL (Institute for Community Living) Address of Agency's Main Office: 125 Broad Street Phone number of Agency's Main Office: Program Name: PROS (Personalized Recovery Oriented Services) Address of Program: 2384 Atlantic Avenue Phone number of Agency's Main Office: ext.2154 Completed by: Your name: Your title: Your address: Broader agency name: Address of agency s main office: Phone number of agency s main office: Program name: Address of program: Phone number of program s main office: Does your agency currently or plan to provide mental health, substance abuse, or primary care services? Yes or No Does your agency plan to provide Health Home Care Coordination? Yes No Undecided Page 2 of 17

3 Please note: if you answered no to both of the above questions, you have finished the survey. Please continue to our online survey input tool to record your responses. OCFS Readiness Assessment Tool Information about Your Present Medicaid Involvement: The Managed Care transition will affect an agency in direct proportion to the amount of revenue the agency derives from Medicaid. Percentage of current reimbursement for primary and/or behavioral health services coming from Medicaid Less than 10% 26% to 50% More than 75% 10% to 25% 51% to 75% Do not know/ Not applicable Percent of current reimbursement for primary and/or behavioral health services coming from commercial insurances Less than 10% 26% to 50% More than 75% 10% to 25% 51% to 75% Do not know/ Not applicable Does your agency currently provide onsite primary health services? Yes No What type(s) of onsite primary health services does your agency provide? Routine/Emergency Medical Vision/Dental Medication Management Evaluation/Assessment Consultative/Educational Liaison with other primary health/specialty providers Does your agency plan to continue to provide onsite primary health services? Yes No Undecided Does your agency plan to pursue Article 28 licensure? Yes No Undecided Does your agency currently provide onsite behavioral health services? Yes No What type(s) of onsite behavioral health services does your agency provide? Evaluation/Assessment Medication Management Individual/Group/Family Therapy Crisis Intervention/Behavioral Management Page 3 of 17

4 Consultative/Educational Liaison with community providers Does your agency plan to continue to provide onsite behavioral health services? Yes No Undecided Does your agency plan to provide Health Home Care Coordination? Yes No Undecided Adapted Addendum and Trauma Informed Care Questions I. Practice Model: Does your agency have an explicit child welfare practice model? Yes No Please describe core components: II. Early Identification and Screening: Authorization to provide Medicaid-funded services requires a determination of eligibility and demonstration of need, as evidenced by screening Please list the screening and diagnostic evaluation tools used in your program for children and families (include any specific to the child, parenting, family functioning, trauma Page 4 of 17

5 assessments, mental health assessments, etc.). If your program does not use any specific screening tools, please indicate by writing NONE in the space provided below. III. Intervention Models and Evidence-Based Practices: The availability of evidence-based service is an advantage for agencies hoping to contract with MCO/HHs Please list any specific intervention models and/or evidence-based practices used in your program currently (e.g., CBT, TF-CBT, FFT, MST, parent training models, etc.) If none, please indicate by writing NONE in the space provided below. IV. Outcome Measures and Tracking: MCOs and HHs are evaluated by state government according to client outcome, and require outcome data from contracting service providers How does your program track client progress and outcomes? Please list any measures you utilize to track outcomes (standardized or non-standardized). If none, please indicate by writing NONE in the space provided below. V. Service Array: MCOs and HHs are responsible for creating comprehensive and integrated plans of care, and value contractors that can provide broad arrays of medical, behavioral health, and substance abuse services Page 5 of 17

6 Please list all services behavioral health and auxiliary services - provided by your agency as well as collaborating providers/agencies. If none, please indicate by writing NONE in the space provided below. Page 6 of 17

7 VI. Trauma Informed Care Principles In our agency, 1. We have a system in place to orient families to the rules and expectations of the program. 2. We train and supervise staff on trauma informed principles and practices. 3. We have a system in place to ensure that our physical environment is safe and welcoming for consumers. 4. We develop rules and regulations that are sensitive to the needs of caregivers and children who have experienced trauma. 5. We have a system in place to ensure that the suggestions, needs, and perspective of families, informs the decisions we make. 6. We have a clearly defined plan or protocol for management of crises with families that have been clearly communicated to all staff. 7. Services focus on what happened to you rather than what's wrong with you. 8. We (or collaborating agencies) are implementing at least one evidence-based trauma treatment approach to help families heal from past traumatic experiences. 9. We routinely screen and assess for trauma in caregivers and children 10. We have a supervisory process to address the impact of our work on the staff s emotional and physical wellbeing. Strongly Agree Agree Neutral Disagree Strongly Disagree Not Applicable/I don t know Page 7 of 17

8 EHR & IT Use in Behavioral Health: Do your programs use electronic billing software (either the billing module of an EHR system or a separate billing software system)? Yes, at all sites Yes, at some but not all sites No, but we are currently in progress towards electronic billing implementation No, our programs do not use electronic billing (Please explain): Do your programs use a billing clearinghouse? Yes Not sure No Do your programs use a separate care coordination software system? Yes, at all sites No, but we are currently in progress towards care coordination software implementation Yes, at some but not all sites No Not sure Page 8 of 17

9 Do your programs use an Electronic Health Record (EHR) for clinical/service documentation? Yes, at all sites No, but we are currently in progress towards EHR implementation Yes, at some but not all sites No, our programs do not use EHRs. (Please explain): Please answer the following series of statements as either yes/no, or on a scale from 1-5 as defined below: 1= We are not at all ready (we will definitely need technical assistance and guidance to get this done in a timely manner, and do not currently have an infrastructure in place that is sufficient) 2= We are somewhat ready (we are likely to need technical assistance to get this done in a timely manner, and will need an assessment of our current infrastructure to determine what else is needed) 3= We are moderately ready (we may or may not need technical assistance to get this done on our own in a timely manner, and may need some assistance with determining if our infrastructure is sufficient) 4= We are mostly ready (we are unlikely to need technical assistance to get this done on our own in a timely manner, and are confident that our infrastructure will be ready) 5= We are definitely ready right now (we currently have the needed knowledge, resources, infrastructure, and plans in place) OCFS Voluntary Agency Addendum Questions -- Please respond whether you have completed an MCTAC readiness assessment previously or not. Readiness Item Rate your organization s ability to identify areas of potential financial and legal risk Rate your organization s understanding of staff certification and credentialing Readiness Rating (1-5) or Page 9 of 17

10 requirements by MCO Readiness Item Readiness Rating (1-5) or Rate your organization s ability to delegate responsibilities to identified program leads, and to respond to external requests for information timely. Rate your organization s level of understanding of Health Home HIT requirements Rate your organization s understanding of the role of the Health Home care manager and the relationship to internal foster care agency staff The approval of your organization s board is required for MCO contracting. Your organization has explored a line of credit in anticipation of lag time between start-up and reimbursement. Your organization has inventoried the amount and type of health care services currently being provided Your organization has discussed outsourcing some/all of the health care services currently being provided Your organization s Quality Assurance Officer reports directly to senior executive administration The individual(s) responsible for intake have been trained on Managed Care requirements Page 10 of 17

11 Please identify the state agencies that oversee programs your agency currently operates: OCFS only OASAS (Office of Alcoholism and Substance Abuse Services) NYSED (New York State Education Department) OMH (Office of Mental Health) OPWDD (Office for Persons with Developmental Disabilities) Other Please specify This assessment was completed by: Myself Agency team (e.g., Leadership team) Other This readiness assessment is being filled out for an agency that provides services for which COUNTY OR COUNTIES? Please specify: Has your agency previously completed a preparedness assessment for the Managed Care Technical Assistance Center? Yes No I don t know If your agency has completed an assessment, you are ready to submit. If your agency has not, please continue with the remainder of the assessment. Page 11 of 17

12 Please answer the following series of statements as either yes/no, or on a scale from 1-5 as defined below: 1= We are not at all ready (we will definitely need technical assistance and guidance to get this done in a timely manner, and do not currently have an infrastructure in place that is sufficient) 2= We are somewhat ready (we are likely to need technical assistance to get this done in a timely manner, and will need an assessment of our current infrastructure to determine what else is needed) 3= We are moderately ready (we may or may not need technical assistance to get this done on our own in a timely manner, and may need some assistance with determining if our infrastructure is sufficient) 4= We are mostly ready (we are unlikely to need technical assistance to get this done on our own in a timely manner, and are confident that our infrastructure will be ready) 5= We are definitely ready right now (we currently have the needed knowledge, resources, infrastructure, and plans in place) Readiness Readiness Item Rating (1-5) or Understanding MCOs: Familiarity with MCO business circumstances and operational methods will be an asset to Foster Care agencies during the Managed Care transition Your organization currently holds contracts with one or more managed care organizations Your organization has identified a point person in the organization who is responsible for understanding MCO priorities; directing agency policy and interactions Your organization has held meetings with leadership of the MCOs to understand their expectations and discuss opportunities to work together on system priorities Your agency/facility leadership team knows and understands the array of services provided within your system Your organization s board is actively involved in planning for transition to Managed Care Your organization s board would benefit from technical assistance specifically targeted for board members Rate your organization s readiness to meet with MCO leadership to understand their expectations and discuss opportunities to work together on system priorities Rate your organization s readiness to market services to an MCO MCO/HH Contracting: Instead of receiving an assigned Medicaid per diem rate from the government, agencies will be contracting with MCOs and HHs concerning service provision and payment The organization has identified an individual to be responsible for providing oversight to Page 12 of 17

13 Readiness Readiness Item Rating (1-5) or MCO contracting Rate your organization s capability to understand the requirements of the managed care contracts you have Rate your organization s capability of assessing compliance with the requirements of the managed care contract you have Rate your fiscal staff s capability of assisting with pricing issues during contract negotiations Rate your fiscal staff s ability to readily compare actual to anticipated revenue and expense by contract Rate your organization s understanding of CMS compliant codes that will be used for billing Rate your organization s ability to identify areas of potential financial and legal risk. The approval of your organization s board is required for MCO contracting Your organization has explored a line of credit in anticipation of lag time between start-up and reimbursement Rate your organization s understanding of staff certification and credentialing requirements by MCO Communication /Reporting (Services authorization, etc.): Close, effective contact with MCOs and HHs will be essential for provider agencies Your organization has a designated liaison responsible for communication and reporting with the MCOs Your organization knows the reporting requirements for the MCOs in your region with which you contract Your organization knows the name and contact information for the Provider Relations Department for each MCO with which you contract Rate your organization s knowledge of the MCO data exchange requirements and the required formats for submission Rate your organization s knowledge of the steps for member verification for each plan and who within the plan to contact when questions arise Rate your organization s ability to delegate responsibilities to identified program leads, and to respond to external requests for information timely IT System Requirements: Agencies may need different or upgraded IT in order to satisfy MCO/HH contract requirements Your organization has determined whether there are specific IT system requirements with which you will need to comply when working with the MCOs/HHs Rate the capability of your organization s IT system to handle the following functions: Centralized scheduling Clinical data with a Meaningful Use Certified Electronic Health Record (treatment plans, medication prescribing & management, progress notes, etc.) Submission of claims electronically (using both 837i and 837p billing formats) Financial accounting and revenue cycle management tools Page 13 of 17

14 Readiness Readiness Item Rating (1-5) or Reporting Quality Assurance Gather, analyze, and use client outcome data Rate the capability of your IT system to integrate functions for client information; services utilization and financial information, including payer type by client Your IT infrastructure meets HIPAA security standards and your access controls adequately mitigate the risk of breaching PHI Rate the capability of your organization to run formatted and ad hoc reports from your electronic health record and billing applications Your organization understands the clinical information that must be available /maintained for the members you are serving Your organization is connected to the Regional Health Information Organization (RHIO) for your service area Rate the capability of your IT system to report out client and services information to all major payors Rate your organization s level of understanding of Health Home HIT requirements Level of Care (LOC)/Level of Need (LON) Criteria/Utilization Management Practices: Approval to deliver and be paid for services will require submission of specific evidence of client need to MCO/HHs Your organization has an individual responsible for knowing MCO requirements and procedures regarding communication of LOC/LON for each MCO Your organization has an individual responsible for knowing MCO requirements and procedures regarding utilization management practices for each MCO If yes to above statement, this individual has information concerning LOC/LON and utilization management for each MCO in your region Rate your organization s readiness to meet MCO service authorization requirements, including time frames Rate the capability of your clinical supervisors to understand the MCO utilization management requirements and supervise staff to practice accordingly Rate the capability of staff members in your organization to understand and comply with requirements for medical necessity, and to effectively meet MCO LOC/LON and utilization management expectations Rate your staff members capability to articulate the clinical need for services, including the ability to translate psycho-social issues, such as homelessness, into a clinical need Regular training is provided to assure a current understanding of LOC/LON and utilization management expectations Your organization is capable of assessing whether staff are able to effectively work within the LOC/LON/UM expectations established by the MCO Your organization has a mechanism for providing feedback to/having discussions with MCOs concerning LOC/LON,UM, denials and appeals expectations Rate the capability of your organization to monitor ongoing authorizations and prompt staff to seek initial and re-authorizations when appropriate Page 14 of 17

15 Readiness Item Your organization has an individual responsible for knowing MCO requirements and procedures for obtaining authorizations for covered services Your organization has an individual responsible for knowing MCO requirements and procedures for transition of care Version 2/18/2015 Readiness Rating (1-5) or Member Services/Grievance Procedures: Agencies may need to respond to MCO/HHs inquiries regarding provision and quality of services, and may also need to address MCO/HHs decisions regarding service approvals/denials Your organization has assigned a person to be responsible for understanding MCO member services expectations Your organization has assigned a person to be responsible for understanding MCO complaints, grievances and appeals processes Rate your organization s ability to train staff regarding MCO Member Services Rate your organization s ability to train staff regarding MCO complaints, grievances and appeals processes Interface with Physical Health, Social Support and Health Homes: Agencies will need to establish relationships with other parties on behalf of their clients in order to assure that all services in a comprehensive plan within and outside of the agency itself are provided Rate your organization s ability to effectively interact with physical health providers on behalf of the recipients you serve Rate your organization s ability to effectively interact with social services providers on behalf of the recipients you serve Rate your organization s ability to effectively interact with Health Homes on behalf of the recipients you serve Your organization works closely with inpatient providers to coordinate linkages and transition to and from levels of care Your organization has contracted with one or more Health Homes Rate your organization s understanding of the role of the Health Home care manager and the relationship to internal foster care agency staff Your organization has inventoried the amount and type of health care services currently being provided Your organization has discussed outsourcing some/all of the health care services currently being provided Quality Management/Quality Studies/Incentive Opportunities: An agency s ability to monitor and manage the quality of its service will directly affect the size and duration of its MCO/HH contracts Your organization has an individual responsible for managing the Quality Assurance/ Quality Study expectations of MCOs Your organization has sufficient staff assigned to the QA function Staff members in your organization have been made aware of the MCO quality expectations and QA procedures have been shared with staff Rate your organization s understanding of QARR and HEDIS measures for Physical Health Page 15 of 17

16 Readiness Readiness Item Rating (1-5) or and Behavioral Health services Rate the capability of your organization s clinical practices to meet established MCO Quality Assurance/ Quality Study expectations Rate the capability of the organization s QA function to closely tie to your management information system Rate the capability of your supervisors and clinical staff to receive and then act on regular QA reports Rate the capability of the organization s QA function to maintain records of managed care appeals and suggest strategies for improving relationships and /or modifying service delivery to reduce denials Patient satisfaction surveys or Perception of Care tools are a function of your organization s QA process Your organization s Quality Assurance Officer reports directly to senior executive administration Finance and Billing: Payment for Medicaid-funded services will no longer be made to agencies via their per diem rates; financial offices must learn and master MCO/HH business practices Your organization has an individual (or a Financial Management consultant) who has experience billing MCOs Rate the ability of your organization to submit clean claims to MCOs on a timely basis Your organization understands the appeals process for denials of claims Rate your organization s ability to appeal denied claims: read remittances and resubmit Rate the ability of your organization to accurately capture and report the unit costs of services being reimbursed by the MCOs by program and location Rate the ability of your organization to translate Unit costs into Episode of Care costs Rate the ability of your organization to monitor the differential between the Medicaid payment and your cost, by service type as well as by episode of care Rate the capability of your organization to regularly communicate cost, revenue, and service value information to all staff Rate the integration of your organization s finance, quality improvement, and clinical departments, and the communication among these groups Rate the success of your revenue cycle management infrastructure, building on the service delivery process, to capture and collect every dollar owed to the organization by all payers. Good process would include monitoring and addressing billing collection issues on a daily or weekly basis Rate the capability of your business office to conduct internal service audits to ensure that documentation of services in patient records can withstand an external audit Rate the quality of your organization s corporate compliance process, including whether it includes a compliance plan led by a designated compliance officer and supported by internal monitoring and auditing Access Requirements: MCO/HHs will be accountable for timeliness of response to member need; agency providers will likewise be Page 16 of 17

17 Readiness Readiness Item Rating (1-5) or accountable Rate the familiarity if your organization with Managed Care plan requirements for timely access to services Rate the capability of your organization to demonstrate that it can meet Managed Care Plan requirements for timely access to services You have a system in place to identify the payor source at the point of service The individual(s) responsible for intake have been trained on Managed Care requirements Demonstrating Impact/Value (Data Management & Evaluation Capacity): Agencies will be expected to prove the worth of their services by measuring processes and outcomes Your organization has identified, trained, and provided the appropriate software application support to an individual responsible for data analysis Rate the ability of your organization to collect data related to the volume of services provided Rate the ability of your organization to collect data related to the clinical impact on the consumers of services provided (quality of care) Your organization considers both internal as well as external data sources (such as Medicaid claims viewed through PSYCKES) as you look for evidence of your clinical impact MCO quality expectations have been shared with staff members Clinical staff members routinely review data being collected about key service delivery processes and clinical outcome measures Rate the ability of your organization to demonstrate the value of your services (the cost/quality equation) to payers compared to benchmarks Your organization has the necessary information to understand the outcomes and related measures that define success for the MCOs with which you work Page 17 of 17

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