Managed Care Technical Assistance Center Kick-Off Forum FAQs Updated

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1 1. Billing When will providers receive billing codes? A draft manual will be sent out shortly. All Plans and providers will use the same coding construct, which will crosswalk procedure code and modifier code combinations back to fee for service rate codes. 2. Billing Will providers have access to a system that uploads claims to Managed Care Organizations (MCOs)? If yes, will the State be maintaining that system? 3. Billing Will there be training for coding, especially evaluation/management codes. 4. CDT How will Medicaid Managed Care Plans handle Continuing Day Treatment (CDT) programs when it s not Fee For Service? All Plans will need to accept web-based claims similar to epaces. New York State (NYS) will provide additional guidance in the future. The State in cooperation with the Plans will be releasing a standardized billing and coding manual for behavioral health services. The Managed Care Technical Assistance Center (MCTAC) will also assemble a comprehensive list of Plan contact information including billing support. Plans as part of the qualification process are also required to train behavioral health providers on billing and coding. Further, additional MCTAC trainings are being planned for providers. Medicaid Managed Care Plans will be required to reimburse CDTs at government rates, which are effectively Fee for Service, for the first two years after the regional carve-in of behavioral health services and start-up of Health and Recovery Plans (HARPs). The Plans will have Utilization Management authority from the outset of coverage of CDT in their plans. The billing and coding manual includes reimbursement provisions for CDT. The provider, Plan and State will be able to match the billing codes to expected government rates to assure accurate reimbursement. 1

2 5. CDT If you are currently a licensed CDT provider with a cap on the number of patients you can see, will that cap be lifted? Currently, the CDT capacity is established as the number of individuals that can be on site at any one time, based on space and staffing. The State does not anticipate expanding the cap. 6. Children s Behavioral Health Implementation 7. Children s Behavioral Health Implementation What will happen with providers currently serving children who have Medicaid, but parents are on private health insurance? How will children in Foster Care be impacted by Medicaid Redesign? Children covered by comprehensive third party insurance or who are dually enrolled in Medicare/Medicaid are excluded from Medicaid Managed Care enrollment. This policy is under review. The Medicaid covered health and behavioral health services for children in foster care will transition to Medicaid Managed Care in January The program design is still being developed. If you would like to receive information regarding the Children s Behavioral Health implementation please sign up for our list serve by following the link: 8. Contracting If MCOs are not mandated by NYS to contract with a provider, will Plans still give other providers contract? An MCO (both Mainstream and HARP) is required to offer contracts to behavioral health programs serving 5 or more of its enrollees. For programs licensed by Office of Mental Health (OMH), the requirement is program specific (i.e., all of an agency s MH clinics, but NOT necessarily its Personalized Recovery Oriented Services (PROS) and CDTs unless each of them also served 5 or more of its enrollees.) An MCO can contract with all of an agency s mental health programs even if one or more of its programs did NOT serve 5 or more of the MCO s enrollees. For agencies with one or more licenses from Office of Alcohol and Substance Abuse Services (OASAS), and one of its programs 2

3 9. Contracting What American s with Disabilities Act (ADA) rules apply under Medicaid Managed Care? service 5 or more enrollees of an MCO, the MCO is required to put all of the agency s OASAS programs in its network. Plans may offer contracts to providers other than those they are mandated to offer contracts to. As State contractors in the Medicaid Managed Care and Family Health Plus programs, Managed Care Plans are responsible for compliance with Title II of the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, as well as other applicable State and local antidiscrimination laws which include protections for people with disabilities. It is the responsibility of the Plan to ensure that it offers services that are accessible to its members with disabilities, through its network providers, or if necessary through out-of-network care. The State requires each Managed Care Organization to submit an ADA Compliance Plan describing in detail how the organization will make its services, programs and activities readily accessible by individuals with disabilities, including any provisions for reasonable alternative methods for making those services or activities accessible, if necessary, such as a referral system. In order to be able to assess the capacity of its network to meet the above requirements, Plans will be inquiring into the accessibility of their network providers. Also, please note that providers are required to comply with all applicable Federal, State and local laws, rules and regulations, including applicable provisions of the ADA, independent of the advent of Medicaid managed care. It is suggested you consult with your legal counsel to ensure that you are aware of and in compliance with such requirements. 10. General Is the State funding HARP services by reducing State Aid for vocational services? No, State Aid will not be affected by the transition to managed care. 3

4 11. General The behavioral health benefit for individuals with Social Security Income (SSI) are carved out of the benefit. Is this going away? 12. General Will MCOs still have a formulary for psychiatric drugs? 13. General Is client transportation for continuing outpatient treatment covered? Yes, all Medicaid behavioral health services for individuals with SSI enrolled in Medicaid Managed Care will be managed by MCOs. (Note: The one exception is rehabilitation supports for residents of community residences. These will be excluded from the benefit package for all Plans except Fully Integrated Dual Advantage (FIDAs) for at least the first year.) Yes, MCO s will continue to maintain formularies for psychotropic medications. NYS s prescriber prevails provision will allow individuals to access non-formulary drugs after their physician consults with the MCO and provides documentation that the drug is medically necessary and warranted. Transportation to behavioral health services is considered nonemergency medical transportation. It will continue to be covered under Medicaid transportation policy guidelines. Currently, these services are managed outside of the Managed Care benefit. 14. General Will the State s behavioral health managed care implementation occur by zip-code? 15. General How do OMH residential treatment facilities fit in with behavioral health Managed Care? 16. General Is the State converting OMH Clubhouses to Medicaid and what happens to access for individuals who are not eligible for Medicaid Managed Care? Implementation for ADULTS will occur as a phase in with NYC implementation on 4/1/15 and the rest of State implementation on 10/1/15. Implementation for children, which is under development, is scheduled for 1/1/16. Residential Treatment Facilities are a children s program only. The implementation plan for children will address residential treatment facilities. OMH Clubhouse is not a Medicaid eligible service. However some of the services that Clubhouses provide may be a Medicaid reimbursable service. Some of the clubhouses might want to become Home and Community Based Services (HCBS) providers. There is no HCBS service called Clubhouse. Individuals who are Medicaid eligible will continue to have access to Clubhouses whether they are HARP enrolled or not, but unless they are receiving a HARP approved (or in lieu of ) HCBS service, their 4

5 17. General Is there Medicaid Managed Care for dual eligibles? 18. General For dual eligibles and the uninsured, will there be an option to purchase into the HARP? Is State Aid funding going to managed care companies? 19. General How will the State measure outcome based performance versus the traditional measure on volume of services provided? 20. General Are any new Managed Care Plans with national experience seeking to come into Western New York? 21. HARPs Are HARPs required to have case managers? activities will be State-aid paid. Please note that at this point NYS is not taking State Aid away from clubhouses. Dual eligibles will not be enrolled in Mainstream Managed Care at this time. The Fully Integrated Dual Advantage Program will be available to duals January 1, 2015, and will include the State Plan behavioral health benefit. The uninsured can purchase insurance through the NYS health exchange. Only Medicaid Managed Care eligible individuals may enroll in a HARP. Spend downs, Medicare/Medicaid dual eligibles and those with third party insurance continue to be excluded from Mainstream Medicaid Managed Care. This policy is under review. State aid on the mental health side will continue to fund services through counties or directly from OMH. State Aid is not going to Medicaid Managed Care companies. The State is working on developing social/recovery outcomes to evaluate quality of services provided. The State is currently discussing a process for qualifying new Plans that come to NYS. However, all Medicaid Managed Care Plans desiring to operate in NYS will need to qualify to manage the Mainstream behavioral health benefit. Not all Plans are required to be a HARP. HARPs are required to participate in care management. The expectation is that face to face care management will be done through the Health Homes. Health Home Case Management capacity should be sufficient. However, the State is engaged in a discussion with Plans if there is a temporary shortage of Health Home care management capacity. 5

6 22. HCBS Will there be any additional necessary licenses for Home and Community Based Services (HCBS) required for providers? No, HCBS services are not licensed services. Providers need to be designated to provide HCBS services, but there is no license required. There is a separate application form for each service now available on-line, so providers must apply to be designated for each service they wish to provide. 23. HCBS How will family support services be included in the initial screen of HCBS? 24. HCBS Do providers need to get designated individually with OASAS and OMH, or will one designation cover both? 25. HCBS If providers already have contracts with MCO s, do they need to revise existing contracts to cover HCBS? 26. HCBS Will MCO s know who the designated HCBS providers are, in order to facilitate contracting? 27. HCBS How do associations, agencies, and non- Medicaid providers connect with HCBS services? Information regarding Home and Community Based Services can be found at: HCBS eligibility for services will be determined through a complete functional assessment and a person centered plan of care will be developed. This may include family support services. The State will offer one designation that will allow services to both OMH and OASAS HARP enrollees. Yes. HCBS are not currently provided through Medicaid Managed Care. Yes, once providers have been designated, Plans will be provided with the list. Entities that are interested in providing HCBS services should follow this process: Complete the online HCBS application available on the OMH website at: s-application/ HCBS Application forms will be reviewed and the results of the review will be communicated on an on-going basis 6

7 28. HCBS Where can I find more information regarding non-medical transportation? Becoming designated to provide an HCBS service does not guarantee business or contracting privileges. An agency that is designated to provide services may choose not to provide the service for which they were designated. All HCBS Applications were due December 5, 2014 for NYC providers. Applications submitted by NYC providers after that date may not be considered in time for Managed Care companies to contract with as they assemble their HCBS network. More information on rest of State deadline submission will be forthcoming. Additional information regarding non-medical transportation can be found in the provider manual located at: HCBS For HCBS Peer Services, which services will be reimbursable? 30. HCBS Will the number of HCBS visits be limited once individuals move to Managed Care? 31. Health Home How do MCOs interact with Health Homes? If child or adult is enrolled in Health Homes, how does that affect authorizations that might be required? What about Health Homes and HARP individuals? Additional information regarding Peer Services can be found in the HCBS provider manual located at: NYS is discussing potential limits with the Center for Medicare and Medicaid Services (CMS). NYS is also developing rules on concurrent use of HCBS and State Plan Services. The answer to this question may be different for adults and children. There is currently a model Administrative Services Agreement governing the relationship between health homes and managed care Plans. The agreement can be found at this link: health_homes/docs/administrative_health_home_services_agreemen 7

8 t.pdf. NYS continues to work with Plans and Health Homes to clarify the roles and responsibilities of Plans and Health Homes regarding care coordination. The general expectation is that Plans and Health Homes work as a team to improve the care that is delivered to Medicaid members. For Health Homes and Plans, the State will issue guidance that clarifies Health Home responsibilities versus MCO responsibilities and how they will work together. The State has recently established new tier of health home services, Health Home Plus (HH+), for select populations. Link to Department of Health (DOH) Health Home Plus webinar: health_homes/docs/ _hh_imp_43.wmv HARP enrollees will automatically be eligible for Health Homes. The Plan will make every effort to get these individuals engaged in Health Homes. All HARP members will receive an initial HCBS eligibility screen. It is expected that the Health Home care manager will complete the HCBS screen and full HCBS assessment when indicated. This is contingent upon approval by CMS. Health Home care managers will work with individuals to complete individual plans of care. Service utilization will be subject to the authorization policy determined by the MCO/HARP. 8

9 32. General How does the behavioral health transition affect people who are in prison and jail? Individuals that have Medicaid before incarceration retain their membership through the first of the month of their incarceration. If an individual is in jail or prison, they are not eligible for Medicaid for services provided in the jail or prison. In cases where Medicaid knows of an individual s incarceration, the individuals are suspended from Medicaid and disenrolled from the managed care plan. Individuals released from jail within 90 days are reenrolled into their Plan. Individuals coming out of jail or prison after 90 days must enroll into a Managed Care Plan. Individuals who are incarcerated have their Medicaid suspended after 30 days and will not receive Health Home services until they are discharged. However, the Health Home that is assigned to that individual may work with county or local jails, prisons, and/or Department of Corrections and Community Supervision (DOCCS) to make sure they are aware that the Health Home will provide services upon discharge. 33. Housing Are OMH Rehabilitation Supports for Community Residence (Community Residences) included as a HARP benefit? 34. Network In the mandatory contract list that MCOs received, will they also find out how many Medicaid lives are being served by providers. The concern is that MCOs will However, the State is working on a strategy for connecting Medicaid Managed Care Plans to individuals coming out of jail or prison. NYS will provide additional information at a later date. Rehabilitation Supports for Community Residence have been excluded from Medicaid Managed Care and HARPs for at least the first year. They are included in the FIDA benefit. NYS is committed to ensuring that individuals continue to receive care from their current providers, regardless of a provider s Medicaid patient population size. For the initial two years of operation, MCOs will be required to contract with any State licensed 9

10 only contract with large providers and small providers will get lost in the mix. behavioral health provider currently serving at least 5 Medicaid managed care enrolled beneficiaries. The State already made available data to the Plan. There is no distinction in the mandate for providers who serve 5 Plan members as distinguished from providers who serve 200 Plan members. 35. Opioid How do Opioid Treatment Programs fit into behavioral health managed care? 36. Prior Authorization 37. Prior Authorization What will happen with the Mental Health Fee for Service Clinic 30/50 visit payment reduction? Regarding authorization, how does the State do analysis for federal parity law for Medicaid? 38. PROS Will MCOs be able to pick and choose which Personalized Recovery Oriented Services (PROS) they want to provide? Additionally, for continuity of care purposes Plans must allow members to continue with their care provider for the current episode of care. Plans may use acceptable UM protocols to review duration and intensity of this episode of care. This requirement will be in place for the first 24 months of the contract. It applies only to episodes of care that were ongoing during the transition period from Fee for Service to managed care. MCOs will be required to contract with all Opioid Treatment programs in their service area to ensure regional access and patient choice. Under managed care the 30/50 visit payment reduction does NOT apply. Managed Care Plans will do utilization review or provider outlier analysis to ensure appropriate use of Medicaid resources. At the State level, we are reviewing guidelines with parity in mind. NYS realizes the importance of this issue and will provide further guidance at a later date. PROS will be part of the mainstream Plan. MCOs will contract with the whole PROS program, not selected services in a PROS. Persons in PROS develop a service plan identifying the services in the PROS that are desired by both the client and PROS staff. The MCOs will review and approve (or request a change to) the plan, based on the explanation provided by the PROS regarding the client s goals, deficits and strengths and appropriateness of the selected services. 10

11 39. Rates For individuals having to create budget projections, is there thought on revising Fee for Service rates for Mental Health clinic? 40. Rates Can Plans propose to providers rates other than the State Fee for Service rates? 41. Rates Will the $2500 per member per month premium go to the Plans? The Fee for Service for APG rates for free standing clinics including LGUs are going to be slightly revised on January 1, Any rate changes for MH clinics will have to be paid by MCOs under the government rates policy. Plans must pay at least the Medicaid rates by law unless the State approves an alternative payment arrangement proposed by an MCO that is voluntarily agreed to by the contracted provider. Yes, $2500 is approximately the proposed monthly premium for HARP members in non-hiv/snp HARPs in NYC (different premiums will apply in various rate regions outside of NYC). This premium will go to the HARPs and they in turn pay the providers for services delivered to their members. 42. Rates Will there still be Medicaid Fee for Service? Yes. Not everyone will be enrolled in Medicaid Managed Care (e.g., dual eligible, most new enrollees in Medicaid) and Fee for Service will need to be maintained for these populations. 43. Rates With Government rates, can there still be alternative payment arrangements between Plans and providers? 44. Rates Will OASAS Ambulatory Patient Group (APG) rates apply to hospital based programs upon transition to a fully managed system? NYS anticipates that alternative payment methodologies will be developed for behavioral health services. All such proposals must be submitted to NYS for approval before MCOs can include any such arrangement in their provider contracts. For the duration of government rates, providers cannot be compelled to agree to these arrangements. Yes. APG payment amounts will be required for hospital based OASAS certified outpatient and opioid clinics upon transition to the managed care benefit package. Per statute, the APG payments will be in place for two years from the date the benefit is included in the benefit package. 11

12 45. State Oversight and Monitoring 46. State Oversight and Monitoring 47. State Oversight and Monitoring Will there be changes to the current vocational rehabilitation (VR) reporting elements for OASAS funded VR services delivered in OASAS Part 822 certified clinic and Opioid programs? Do we have data as to why programs are performing poorly for employment? Who specifically do providers reach out to for external appeals? The State will provide additional guidance at a later date. No, however the State intends to collect data on employment and associated factors for HARP members. Health care providers may request an external appeal on their own behalf to obtain payment when a health Plan makes a concurrent or retrospective adverse determination denying health care services as not medically necessary, experimental / investigational, a clinical trial or a rare disease treatment. More information regarding provider external appeals can be found at the Department of Financial Services (DFS) website: 48. Substance Abuse What is LOCADTR? LOCADTR or Level of Care for Alcohol and Drug Treatment referral is the patient placement criteria system required for use in making SUD level of care decisions in NYS. LOCADTR assesses the intensity and need of services for an individual with a substance use disorder. All OASAS providers and Medicaid Plans will be required to use this tool. 49. Substance Abuse 50. Utilization Management Will there be limitation on medication assisted treatment (MAT) with LOCADTR? How will MCOs apply medical necessity review to individuals with existing care plans? No, all MAT is based on patient specific need. For substance use services, the State is working with Plans on implementing the LOCADTR. (See question 48). 12

13 51. Utilization Management 52. Utilization Management 53. Utilization Management Will the State develop standardize treatment plans? Currently MCOs all have their own way of auditing providers. OMH and OASAS also have their own auditing process. How does OASAS LOCADTR apply to cooccurring OMH/OASAS providers? Any plan to do something similar to the LOCADTR for OMH? The State will also review and approve all plan mental health medical necessity and issue guidance to all Plans regarding review and approval for Home and Community Based Services. OMH and OASAS licensed or certified clinics will continue to follow policies and procedures implemented by OMH and OASAS. Clinics contracting with managed care organizations will be subject to MCO performance monitoring as outlined in Plan contracts. The OASAS LOCADTR is mandated for level care place in the OASAS system. For an individual with an OMH licensed program who is in need of SUD services, LOCADTR will be used to make the level of care determination for accessing the OASAS certified programs. OMH does not anticipate having a standardized level care determination tool. 13