Healthier WA and Behavioral Health Care Reform

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1 Healthier WA and Behavioral Health Care Reform Candace Goehring RN MN Director Residential Care Services Aging and Long Term Support Administration February 19, 2016

2 Moving Forward: Healthier Washington 2

3 Washington s vision for creating healthier communities and a more sustainable health care system by: Building healthier communities through a collaborative regional approach Ensuring health care focuses on the whole person Improving how we pay for services Better Health, Better Care, Lower Costs

4 Healthier Washington: Better Health, Better Care, Lower Costs Healthier Washington will transform health care in Washington State so that people experience better health during their lives, receive better care when they need it, and so care is more affordable and accessible. 4

5 We recognize that health is more than health care Health Care 20% Physical Environment 10% Socio-economic Factors 40% Health Behaviors 30% Adapted from: Magnun et al. (2010). Achieving Accountability for Health and Health Care: A White Paper, State Quality Improvement Institute.. Minnesota. 5

6 and that clinical-community linkages are essential for better health outcomes. Collective Impact Home care Peer support Behavioral Health Housing Supportive employment Recovery

7 Goal: A healthier Washington The state will: Lead by example in changing how it purchases insurance programs. By 2020, Washington State will shift 80 percent of health care purchasing from paying for volume to paying for value. Support people and communities in making local decisions to improve health and quality of life. Ensure that people receive coordinated care for physical and mental health and substance use in a way that works for that person wherever they are. 7

8 Community Empowerment and Accountability Accountable Communities of Health will: Bring together diverse public and private community partners to work on shared regional health goals. Identify opportunities for the ACH and community partners to understand and bridge health and quality of life issues Coordinate systems so that services address all aspects of health at both the community and individual levels. 8

9 Practice Transformation Support Washington will develop a Practice Transformation Support Hub to help providers: Accelerate physical and behavioral health integration. Adapt to value-based payment. Develop clinical-community linkages. Facilitate shared learning and develop best practices. 9

10 Performance Measures Washington State Common Measure Set for Health Care Quality is a set of 52 measures to: Standardize the way we measure performance as a state, reducing unnecessary burden on health systems. Ensure equal access to high-quality health care by reducing variation in care and improving health outcomes. Publicly share results to develop a common understanding of what needs to improve and where it needs to improve.

11 Paying for Value/Payment Redesign In partnership with purchasers, providers, and payers, Washington will: Leverage its purchasing power to move 80% of its health market from fee for service to valuebased payments. Test, improve, and bring to scale shared savings and cost of care models. Implement Medicaid payment and delivery models that support full integration of physical and behavioral health. Accountable Care Program Multi-Payer Physical & Behavioral Health Integration Encounterbased to Value-based 11

12 Analytics, Interoperability, and Measurement Washington State will: Develop a consistent set of measures for health performance. Enhance our capacity to exchange information. Bolster analytic capacity. 12

13 Behavioral Health Transformation Today we are going to focus on two transformation initiatives both being implemented April 2016 that support the goals of Healthier Washington Behavioral Health Organizations created by state law to purchase and administer public mental health and substance use disorder services under managed care; and Fully Integrated Managed Care full integration of the financing and delivery of physical health and behavioral health via managed care.

14 Contact us Join the Healthier Washington list: Learn more: The project described was supported by Funding Opportunity Number CMS-1G from the U.S Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

15 Behavioral Health Integration Past, Present, and Future Scott McCarty, Program Manager Behavioral Health Organizations, Division of Behavioral Health and Recovery February 2,

16 What is the Vision for Integrated Behavioral Health Services? 2

17 The First Steps Towards Integration 2014 Legislative Action: 2SSB 6312 Regional Service Areas (RSAs) define new geographical boundaries for the state to purchase behavioral and physical health care through managed care contracts. RSAs were authorized in 2014 legislation and include contiguous counties, contain at least 60,000 people on Medicaid, possess an adequate number of health care providers, and reflect natural and behavioral health service referral patterns. By January 1, 2020, the community behavioral health program within each RSA must be fully integrated in a managed care health system that provides mental health services, chemical dependency services, and medical care services to Medicaid clients 3

18 2014 Legislative Action: 2SSB 6312 Continued State law also created Behavioral Health Organizations (BHOs) to purchase and administer public mental health and substance use disorder services under managed care. The legislation specifically gives the current Regional Support Networks (RSNs) the right of first refusal as the BHO through submission of a Detailed Plan to demonstrated the readiness of their entity to administer SUD treatment services. 4

19 Parallel Paths to Purchasing Transformation 2020: Fully Integrated Managed Care System Transition Period 5 Apple Health Managed Care Plans Behavioral Health Organizations 2016 Regional Service Areas (RSAs) Fully Integrated Purchasing in Early Adopter RSAs

20 2016 Medicaid Purchasing Context Behavioral Health Organization or BHO Regional Service Areas: Behavioral Health Organizations will provide substance use disorder services for all and mental health for individuals who meet the mental health access-to-care standards Apple Health Managed care plans contract for physical health for all Medicaid enrollees and mental health for individuals who do not meet access-to-care standards for services through RSNs The Early adopter Regional Service Area (SWW) Fully integrated managed care plans will contract for all physical and behavioral health Medicaid services and assume full risk for both An Administrative Service Organization for Behavioral Health (ASO-BH) will provide crisis services for this region plus the non-medicaid services for those not enrolled in Medicaid 6

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22 8/2/2015 Complete Q&A period for Detailed Plans BHO Implementation Timeline 12/15/2015 9/1/2015 File BHO WAC 10/30/2015 BHO Detailed Plans submitted to DSHS 12/15/2015 Task Force final report 2/1/2016 Transitional Contracts Start Date 4/1/2016 BHOs to provide services 4/1/2016 BHO WAC Rules effective 8/1/2015 9/1/ /1/ /1/ /1/2015 1/1/2016 2/1/2016 3/1/2016 7/1/ /2/2015 4/1/2016 DSHS starts review of Detailed Plans 7/1/2015 Released Request for Detailed Plan 12/7/2015 DSHS release of evaluation of Detailed Plans to prospective BHOs 12/21/2015 BHO detailed plan evaluation comment period ends 1/8/2016 DSHS publishes review results BHO Milestones BHO Detailed Plan 11/2/2015-1/8/2016 8

23 BHO Request for Detailed Plan From RCW Request a detailed plan from the entities identified that demonstrate compliance with the contractual elements of RCW 43.20A.894 and federal regulations related to Medicaid managed care contracting, including, but not limited to: Having a sufficient network of providers to provide adequate access to mental health and chemical dependency services for residents of the regional service area that meet eligibility criteria for services Ability to maintain and manage adequate reserves, and maintenance of quality assurance processes Any responding entity that submits a detailed plan that demonstrates that it can meet the requirements of this section must be awarded the contract to serve as the behavioral health organization. 9

24 Current and Future Structure 10

25 Current Fee-for Service vs. Managed Care Fee for Service (FFS) Managed Care/BHO Providers hold Core Provider Agreement with HCA and agree to accept Medicaid rates as payment in full- payments made according to established fee schedule Enrollees choose providers from pool of providers willing to accept Medicaid beneficiaries Providers can limit the number of Medicaid enrollees they accept Managed Care entity accepts PM/PM premium as payment for all covered services Managed Care entity contracts with providers to provide services in benefit package and establishes payment methods and rates directly to the provider Must have adequate network to provide timely access to medically necessary services 11

26 Required Elements of Managed Care Quality Review- Implementation of quality programs and entities must have a quality strategy for continuous review and oversight including have an External Quality Review Organization (EQRO) to review compliance with federal requirements and oversight. Network Adequacy- Sufficient number of providers, with an appropriate range of services to meet the medical necessity of the anticipated enrollees in the region. Time and distance standards apply and there can be no waitlist. Grievance and Appeal Rights- Provides a check and balance to protect the enrollee s rights as well as a timely resolution to concerns and requests related to access to care, service provision and choice of providers. 12

27 Future Funding and Contract Flow Block Grant Community Community Prevention Prevention Tribal Services Federal Congress Medicaid Specialty Programs Other Projects DSHS/DBHR General Fund-State/ Medicaid Match Mental Health Providers State Legislature Criminal Justice Treatment Account Behavioral Health Organizations SUD Treatment Providers 13

28 Challenges Maintaining and/or increasing the network of providers to meet the demand Financial risk to manage within the resources provided without regard to demand New process for accessing SUD Services through BHO authorization Understanding each other (SUD/MH language differences) Opportunities Ensures access to all medically necessary services for enrollees Provides protections such as appeals that allow decisions about care to be reviewed Requires quality improvement processes Begins to move the system towards further integration 14

29 Eligibility and Access to Services 15

30 Eligibility Once determined Medicaid eligible, the enrollee is entitled to services defined in the benefit package. The type, scope and duration is based on the medical necessity criteria and specialty services may have standardized medical necessity criteria 16

31 Determination of Medical Necessity Medical Necessity for all Behavioral Health Services is based on the presence of a DSM 5 related diagnosis. (The DSM 5 includes both mental health and substance use disorder diagnoses.) Authorization of Mental Health (MH) Treatment Services are based on DSM 5 Diagnosis and meeting Mental Health Access to Care Standards with the primary diagnosis being MH related. Authorization of Substance Use Disorder (SUD) Treatment Services are based on the presence of a DSM 5 substance related diagnosis and application of the American Society of Addiction Medicine placement criteria following an Assessment. Individuals with co-occurring MH and SUD conditions may receive treatment from two provider types or from a provider that is licensed and staffed for both MH and SUD. 17

32 Medicaid State Plan Benefits In addition to the Mental Health Medicaid State Plan Services currently administered by the RSNs the following Substance Use Disorder Medicaid State Plan Services are be covered by the BHOs and authorized based on Medical Necessity: Substance Use Disorder Services Brief Intervention Treatment Withdrawal Management (Detoxification); Assessment Outpatient Treatment Intensive Outpatient Treatment Inpatient Residential Treatment Opiate Substitution Treatment Services Case Management 18

33 Communications and Ongoing Work 19

34 Communications: Statewide Notification for existing Medicaid Enrollees by letters that are mailed by Apple Health Benefit Exchange New Enrollee s will receive the notification as they apply and are notified of eligibility prior to April 1, 2016 Other communications are being planned jointly with RSNs/BHOs for regional notification of changes and who to contact with questions regarding services Ongoing Work: Washington Administrative Code is being amended to create the rules for the Administrative structure of BHOs and the delivery of services. Other WAC rules are planned for the future to work towards integration of services Revised Code of Washington amendments were done during the 2015 Legislative session to begin to incorporate BHOs into codes with more work to follow in the 2016 session 20

35 Behavioral Health Organization Information Please submit BHO related questions to the BHO Mailbox Health Care Authority Full Integration Project aspx Link to ASAM website ASAM Frequently Asked Questions 21

36 QUESTIONS? Please submit BHO related questions to the BHO Mailbox 22

37 HCA Update: Early Adopter Initiative Isabel Jones Health Care Authority

38 Legislative Direction Substitute Senate Bill (SSB) 6312 passed in 2014 Changes how the state purchases mental health and substance use disorder services in the Medicaid program Directs state to fully integrate the financing and delivery of physical health, mental health and substance use disorder services in the Medicaid program via managed care by 2020 Directs the state to regionalize Medicaid purchase by April, Regional Service Areas statewide 2 Better Health, Better Care, Lower Costs

39 Parallel Paths to Purchasing Transformation 2020: Fully Integrated Managed Care System Transition Period 2014 Legislative Action: SSB 6312 By January 1, 2020, the community behavioral health program must be fully integrated in a managed care health system that provides medical care, mental health and substance use disorder services for Medicaid clients Apple Health Managed Care Plans Behavioral Health Organizations 2016 RSAs Integrated Purchasing in Early Adopter RSAs, with shared savings incentives 3

40 Medicaid purchasing in Early Adopter Regional Service Areas Local Decision-making Agreement by county authorities in Clark and Skamania for a regional service area Strong county involvement in implementation process from start to finish Changes in April 2016 RSN will cease operations March 31, 2016 Health Care Authority (HCA) will contract with Managed Care Organizations (MCOs) at financial risk for full scope of Medicaid physical health, substance use disorder and mental health services on April 1, 2016 Behavioral Health Crisis System will be managed regionally Consumer Choice Consumers will have a choice between Molina or Community Health Plan of Washington, which have been selected through a competitive procurement to provide fully-integrated services 14

41 Current Siloed Medicaid Systems Mental Health Services for people who meet Access to Care Standards (ACS) Medical Services & Mental Health Services for people who do NOT meet ACS Chemical Dependency Services DSHS administers benefits: County-based Regional Support Network (RSN) contracts for mental health services State hospitals provide intensive psychiatric inpatient treatment HCA administers medical benefits (including prescription drug coverage) and mental health benefits for Medicaid enrollees who do not meet ACS Contracts with Healthy Options plans for medical and non-acs mental health managed care services Direct contracts with providers for fee-for-service (FFS) enrollees HCA administers dental benefits via direct contracts with providers. DSHS administers chemical dependency benefits: Contracts with counties and tribes for outpatient services, including opiate substitution treatment Direct contracts with residential treatment agencies for residential services Providers Providers Providers Individual Client 15 Better Health, Better Care, Lower Costs

42 New System: April 2016 For Apple Health clients, physical health, mental health and substance use disorder services will be managed by one managed care organization instead of three systems. Access to Care standards no longer apply; care is provided based on level of care guidelines and medical necessity. Fully Integrated Managed Care contracts require coordination with county-managed programs, criminal justice, long-term supports and services, tribal entities, etc. via an Allied System Coordination Plan. 6 Better Health, Better Care, Lower Costs

43 What services will the MCOs manage? All Medicaid benefits will continue to be defined by the State Plan Fully-Integrated Managed Care Plans will provide all Medicaid physical, mental health, and substance use disorder (SUD) services Fully-Integrated Managed Care plans will also provide services to Medicaid enrollees that complement the Medicaid benefit package, funded by general state funds and federal block grants Examples of these services include: services provided in Institutes for Mental Disease (IMD) interim SUD services, community outreach. Plans must have an adequate provider network in place before enrollment begins 20

44 Different Enrollment Pathways GROUP MEDICAL SERVICES MH AND SUD SERVICES ALICE PLEASE Through FIMC managed INSERT SLIDE Clients enrolled in apple health-managed care plans today HERE Clients who are not enrolled in Apple Health managed care today (e.g. on Medicare, Native American/American Indian people) care plans Through fee-for-service coverage (and additional coverage) Through FIMC managed care plans Through FIMC managed care plans under Behavioral Health Services Only (BHSO), set up for ensuring those enrolled in Medicaid can continue to access services Non-Medicaid No change Through Behavioral Health Administrative Services Organization 8

45 What does this mean for Apple Health clients? Physical and behavioral health benefits will be covered by fully integrated managed care plans no Regional Support Network or county SUD system State Plan benefits stay the same 1 point of contact available for all services, instead of navigating up to 3 systems Still have choice of at least two managed care plans If a client s current managed care plan receives a contract to provide fullyintegrated services, the client can choose to remain with the same managed care plan, or can choose to switch plans. Many things will stay the same, such as: o Interpreter and transportation requests will remain the same for Medicaid client benefits o Pharmacy benefits remain the same clients need to use plan network pharmacies 22

46 What does this mean for providers? Providers must contract with fully integrated managed care plan(s) in order to provide services to a Medicaid client as of April 1, 2016 Providers must be enrolled and in good standing with the State Medicaid program 23

47 How will the crisis system be managed? HCA HCA Contract with BH-ASO Fully Integrated MCO Required sub-contract BH-ASO Required sub-contract Fully Integrated MCO Continuum of Integrated Clinical Services Individual Client 24

48 Additional Functions of BH-ASO Monitor Less Restrictive Alternative (LRA) court orders for individuals who are not eligible for Medicaid Maintain a Behavioral Health ombudsman for SW Region Administer the Mental Health Block Grant, CJTA Funds & Juvenile Drug Court funds, in accordance with local plans Provide limited non-crisis behavioral health services to low-income individuals who are not eligible for Medicaid 12 Better Health, Better Care, Lower Costs

49 Local Implementation Work Developing an Early Warning System to identify risks and options for mitigation, and to establish a triage processes to address emerging issues Monitor the availability of behavioral health and medical services throughout the transition, to avoid disruption or reduction in care before and after April 2016 Build relationships between providers and payers facilitated meetings and Resource Fairs Develop a broad understanding and cross-fertilization across the region to prepare health and social service stakeholders for change Communicate transition changes broadly throughout the community, including to consumers Ensure that behavioral health providers have go-live-critical tools (and procedures) in place to be successful partners in fully integrated managed care systems 30 Better Health, Better Care, Lower Costs

50 Next Steps January-February 2016: Readiness Review & Client Mailings, Community Events March 2016: Client notice of enrollment in managed care plan; updated client handbook; insurance card; new provider orientations and readiness review with providers April 1, 2016: Coverage effective 14 Better Health, Better Care, Lower Costs

51 Questions? Federal Notice: The project described was supported by Funding Opportunity Number CMS-1G from the U.S Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. 31