H EALTH M ANAGEMENT A SSOCIATES

Transcription

1 Request fr Qualificatins (RFQ) fr Medicaid Managed Care Organizatins - Summary/Key Pints - 1. Prgram Design New Yrk is taking a multi-prnged apprach t the incrpratin f behaviral health services fr adults in Medicaid managed care. This apprach is as fllws: Qualified Mainstream MCOs: Fr all adults served in mainstream MCOs thrughut the State, the qualified MCO will integrate all Medicaid State Plan cvered services fr mental illness, substance use disrders (SUDs), and physical health (PH) cnditins. Plans must meet the criteria cntained in this RFQ t qualify t administer the BH benefit. Premiums fr mainstream Plans will be adjusted t reflect the additinal BH benefits f mainstream enrllees. Health and Recvery Plans (HARPs): HARPs are a distinctly qualified, specialized and integrated managed care prduct fr adults meeting the serius mental illness (SMI) and SUD targeting criteria and risk factrs. Within the HARPs, access t an enhanced benefit package will be ffered in additin t all Medicaid behaviral health and physical health benefits. The enhanced array f hme and cmmunity services are fr HARP enrlled individuals wh meet bth targeting and risk factrs, as well as needs-based criteria fr functinal limitatins. The enhanced benefit package will help maintain participants in hme and cmmunity based settings. The qualified HARP, cntracting with Health Hmes, will prvide care crdinatin fr all services including the 1915(i)-like Hme and Cmmunity Based Services in cmpliance with hme and cmmunity-based standards and assurances. New Yrk State is wrking with Plans and Health Hmes t develp clarity arund care management rles and functins. The general expectatin is that: Health Hmes will prvide care crdinatin services, including cmprehensive care management and the develpment f persn centered plans f care; health prmtin, cmprehensive transitinal care; patient and family supprt; and referral and cnnectin t cmmunity and scial supprt services, including t nn-medicaid Services. Plans use data t identify individuals in need f high tuch care management; identify patients discnnected frm care, ntify Health Hmes when members shw up in ERs and inpatient settings; and, mnitr Health Hme perfrmance. HARPs will have an integrated premium established fr this behaviral health ppulatin. They will have specialized staffing requirements and qualificatins alng with fcused behaviral health perfrmance metrics and incentives t achieve health, wellness, recvery, and cmmunity inclusin fr their members. Page 1 f 18

2 Children in Mainstream MCOs: Children's specialty BH services, including all fur BH HCBS waivers perated by OMH and the Office f Children and Family Services, will be included in the mainstream MCOs at a later date. Plans will need t meet additinal standards and cntract requirements fr the management f children s services at that time. The prcess fr integrating children s BH services will be specified by New Yrk State at a later date. Integratin f State Operated Psychiatric Services: OMH is making several changes t the State perated psychiatric system as part f the creatin f Reginal Centers f Excellence (RCEs). The RCE plan includes the establishment f Reginal Centers f Excellence acrss the State alng with a netwrk f state-perated cmmunity-based services that will respnd t lcal needs. The restructuring f State perated psychiatric hspitals ver several years will result in mre than 600 fewer adult state psychiatric beds. As many f the individuals using these beds at admissin r upn discharge will be enrlled in managed care, MCOs will be respnsible fr participating in discharge planning fr their members and prviding access t and verseeing aftercare services. This means that MCOs are nt financially respnsible fr their enrllees wh are admitted t r transferred t OMH psychiatric centers. OMH envisins a cnsumer-riented mdel where Plans will be respnsible fr managing admissins and discharges frm State hspitals, in additin t prviding assistance in mving lng stays ut f State perated facilities. T begin this prcess, OMH is identifying histric and current admissins and lengths f stay at OMH inpatient facilities fr adults enrlled in Medicaid Managed Care. As the RCE restructuring stabilizes, OMH and DOH will wrk with the MCOs t make the plans accuntable financially and prgrammatically fr cntinuing admissins/transfers f their members t the State facilities. 2. Purpse f the Request fr Qualificatins (RFQ) The mvement f the Medicaid behaviral health funding t managed care presents challenges and pprtunities. Carving behaviral health int mainstream Plans ffers the pprtunity t address the full range f health care needs. The integrated health premium will allw Plans t mre effectively help members manage their behaviral and physical health needs in an integrated manner. Additinally, a managed system can purpsefully reinvest savings frm a decrease in unnecessary and expensive hspital stays int recvery services and husing rehabilitatin supprts. Hwever, Medicaid Managed Care Plans in NYS currently manage a limited range f behaviral health services. Many Plans d nt have experience managing the cmplex behaviral health needs f the ppulatins that will be cming int care management. Many f these individuals require a brader array f services t supprt functining in the cmmunity, ften ver lng perids f time. Page 2 f 18

3 Plans must therefre submit applicatins t New Yrk State demnstrating that they have the rganizatinal capacity and culture t ensure the delivery f effective behaviral health care and facilitate system transfrmatin. These applicatins will be reviewed against new behaviral health specific administrative, clinical, prgram, and fiscal standards. Because Plans d nt have the expertise t manage specialty BH benefits, they will need t: Hire in staff with apprpriate expertise r Subcntract with a BH rganizatin that meets the qualificatins. Plans are encuraged t develp a gvernance mdel that includes the experience f their expanded behaviral health netwrk. Hwever, these relatinships cannt substitute fr the Plan requirements included in this RFQ. The purpse f this RFQ is t qualify: Current mainstream Medicaid MCOs in NYS t administer the full cntinuum f MH and SUD services cvered under the Medicaid State Plan fr adults wh d nt meet HARP eligibility criteria r wh qualify but chse nt t enrll. Current mainstream Medicaid MCOs seeking t becme HARPs in NYS t administer the full cntinuum f MH, SUD, and PH services cvered under the Medicaid State Plan as well as the enhanced Hme and Cmmunity Based Service benefit package (1915(i)- like rehabilitatin and recvery services) fr adults with serius mental illness (SMI) and/r SUDs wh meet HARP targeting and risk factrs and/r 1915(i)-like functinal eligibility criteria. NYS will qualify MCOs and HARPs t serve adults in 2 runds based n gegraphic regin and ppulatin characteristics. The first rund will be in New Yrk City (NYC). The secnd rund will be fr the rest f the state. RFQ applicatins fr Plans serving NYC are due by June 6, RFQ applicatins fr Plans serving the rest f the state will be due six mnths later with the exact date t be determined. Additinally the RFQ fr the rest f the state may be mdified based upn experience btained during the NYC qualificatin prcess. The prcess fr integrating children s BH services int managed care will be specified by New Yrk State at a later date. Integratin f all Medicaid BH and PH benefits under managed care will take place as fllws: Adults in New Yrk City n January 1, 2016 Adults in the rest f the State n July 1, 2016 Children in New Yrk City n January 1, 2017 Children in the rest f the State n January 1, 2017 Page 3 f 18

4 3. System Gals, Operating Principles, Requirements and Outcmes Gals: The qualificatin prcess fr MCOs and HARPs is necessary t ensure each has adequate capacity t assist NYS in achieving system refrm gals including: Imprved health utcmes and reduced health care csts thrugh the use f managed care strategies and technlgies including, but nt limited t BH-specific prtcls fr: Member services (intake, referral, crisis respnse) Utilizatin management Clinical management Netwrk management Quality management Data management Reprting and financial management. Transfrmatin f the BH system frm an inpatient fcused system t a recvery fcused utpatient system f care. Imprved access t a mre cmprehensive array f cmmunity-based services that are grunded in recvery principles including: Persn centered care management Patient/cnsumer chice Member and family member invlvement at all system levels Full cmmunity inclusin. Integratin f physical and behaviral health services and care crdinatin thrugh prgram innvatins that address wrkfrce develpment; risk screening; data integratin and data analytics; and specialized case management and care crdinatin prtcls. Effective innvatin thrugh the use f evidence-based practices. Imprved crss system cllabratin with State and lcal resurces, including LGUs, State and lcally funded MH and SUD services, husing subsidies and supprts, the judicial system, welfare prgrams, and ther lcal resurces necessary t prmte recvery utcmes. Delivery f culturally cmpetent services. Assurance f adequate and cmprehensive netwrks with timely access t apprpriate services. Cntinuity f care during the transitin frm fee-fr-service (FFS) t managed care. Principles/Requirements: These gals will be realized in bth new and existing prgrams thrugh the applicatin f the fllwing: Page 4 f 18

5 a) Earlier identificatin and interventin thrugh the use f validated screening tls where available fr cmmn cnditins such as anxiety, depressin, and alchl misuse b) Persn-centered treatment that integrates attentin t behaviral and physical health care and t scial needs within a framewrk that is strengths-based; culturally relevant; incrprates natural supprts; and prmtes hpe, empwerment, mutual respect, and full cmmunity inclusin. c) Use f integrated care mdels such as the Cllabrative Care mdel fr treating BH cnditins in primary care. d) An inclusive culturally cmpetent prvider netwrk that cntains a wide range f prviders with expertise in treating and managing SMI and SUD cnsumers including cmmunity based prviders f behaviral health and substance use services and peer delivered services. e) Efficient and timely service delivery, care crdinatin, and care management with minimal duplicatin acrss prviders and between prviders and the Plan. f) Access t care management and clinical management frm a Health Hme and/r MCO as apprpriate. g) Enhanced discharge planning and fllw-up care between prvider visits. h) Reliance n specialized expertise fr the assessment, treatment, and management f special ppulatins, including lder adults, transitin age yuth, individuals with c-ccurring disrders (e.g. high risk medical ppulatins), individuals experiencing a first episde psychsis (FEP), individuals with SMI and criminal justice r assisted utpatient treatment (AOT) invlvement, and individuals with SMI and/r functinally limiting SUDs. i) Service delivery within a culturally cmpetent cmprehensive system f care, which emphasizes the mst apprpriate, least restrictive settings t prmte and maintain the highest practical level f functining. j) Medical necessity determinatins that cnsider level f need as well as envirnmental factrs, available resurces and psychscial rehabilitatin standards. k) Fr behaviral health, Level f Care and clinical guidelines apprved by the State. l) Fr SUD, Level f Care determinatins based n the OASAS LOCADTR tl. m) Use f natinal data regarding evidence-based and prmising practices as well as data frm NYS regarding utilizatin and unmet needs t guide netwrk enhancements and the allcatin f resurces t supprt individuals in achieving wellness and recvery. n) Use f data-driven appraches t perfrmance measurement, management, and imprvement with regular reprting f results n key perfrmance indicatrs t stakehlders, e.g., cnsumers, prviders, ther member serving systems. ) Heightened mnitring f the quality f behaviral health and medical care fr all members (thse with mild and mderate cnditins and thse with high BH needs) with the use f nging utcme measurements intended t raise expectatins fr imprvement in access, utilizatin, care crdinatin, health and recvery utcmes. p) Regular and nging technical supprt and training and wrkfrce develpment with netwrk BH and PH prviders as well as managed care staff t achieve system transfrmatin and t develp cmpetency in current Page 5 f 18

6 and emerging EBPs and ther best practices. Prmtin f peratinal plicies and prcedures that supprt these principles acrss healthcare prviders, managed care Plans and ther State and lcal agencies. q) Use f financial structures that supprt and/r incentivize achieving system gals. r) Separate tracking f BH expenditures and administrative csts t ensure adequate funding t supprt access t apprpriate BH services. s) Medical Lss Rati (MLR) fr HARPs and BH MLR fr Mainstream MCOs. t) Reinvestment f behaviral health savings t imprve services fr behaviral health ppulatins. u) Enhanced pharmacy management fr individuals with c-ccurring cmplex health, MH and SUD challenges. Outcmes: Achievement f system gals are expected t result in the fllwing utcmes: a) Imprved individual health and behaviral health life utcmes b) Imprved scial/recvery utcmes including emplyment c) Imprved member s experience f care d) Reduced rates f unnecessary r inapprpriate emergency rm use e) Reduced need fr repeated hspitalizatin and re-hspitalizatin f) Reductin r eliminatin f duplicative health care services and assciated csts g) Transfrmatin t a mre culturally cmpetent cmmunity-based, recvery-riented, persn-centered service system. 4. Cvered Ppulatins and Eligibility Criteria This RFQ cvers the inclusin f Medicaid BH services fr adults in mainstream MCOs. Dual eligibles (persns wh are bth Medicaid and Medicare enrlled) are nt included at this time but may be at a later date. Specific eligibility is as fllws: Qualified Mainstream Managed Care Organizatin: All mainstream Medicaid eligible and enrlled individuals 21 and ver requiring behaviral health services. HARPs: Adult Medicaid beneficiaries 21 and ver 1 wh are eligible fr mainstream MCOs are eligible fr enrllment in the HARP if they meet either: Target criteria and risk factrs as defined belw (Individuals meeting these criteria will be identified thrugh quarterly Medicaid data reviews by Plans and/r NY State); r 1 One exceptin: individuals in nursing hmes fr lng term care will nt be eligible fr enrllment in HARPS. Page 6 f 18

7 Service system r service prvider identificatin f individuals presenting with serius functinal deficits as determined by: A case review f individual's usage histry t determine if Target Criteria and Risk Factrs are met; r Cmpletin f HARP eligibility screen. HARP Target Criteria: The State f New Yrk has chsen t define HARP targeting criteria as: Medicaid enrlled individuals 21 and ver SMI/SUD diagnses Eligible t be enrlled in Mainstream MCOs Nt Medicaid/Medicare enrlled ("duals") Nt participating r enrlled in a prgram with the Office fr Peple with Develpmental Disabilities (OPWDD) (i.e., participating in an OPWDD prgram). HARP Risk Factrs: Fr individuals meeting the targeting criteria, the HARP Risk Factr criteria include any f the fllwing: Supplemental Security Incme (SSI) individuals wh received an "rganized"7 MH service in the year prir t enrllment. Nn-SSI individuals with three r mre mnths f Assertive Cmmunity Treatment (ACT) r Targeted Case Management (TCM), Persnalized Recvery Oriented Services (PROS) r prepaid mental health plan (PMHP) services in the year prir t enrllment. SSI and nn-ssi individuals with mre than 30 days f psychiatric inpatient services in the three years prir t enrllment. SSI and nn-ssi individuals with 3 r mre psychiatric inpatient admissins in the three years prir t enrllment. SSI and nn-ssi individuals discharged frm an OMH Psychiatric Center after an inpatient stay greater than 60 days in the year prir t enrllment. SSI and nn-ssi individuals with a current r expired Assisted Outpatient Treatment (AOT) rder in the five years prir t enrllment. SSI and nn-ssi individuals discharged frm crrectinal facilities with a histry f inpatient r utpatient behaviral health treatment in the fur years prir t enrllment. Residents in OMH funded husing fr persns with serius mental illness in any f the three years prir t enrllment. Members with tw r mre services in an inpatient/utpatient chemical dependence detxificatin prgram within the year prir t enrllment. Members with ne inpatient stay with a SUD primary diagnsis within the year prir t enrllment. Page 7 f 18

8 Members with tw r mre inpatient hspital admissins with SUD primary diagnsis r members with an inpatient hspital admissin fr an SUD related medical diagnsis-related grup and a secndary diagnsis f SUD within the year prir t enrllment. Members with tw r mre emergency department (ED) visits with primary substance use diagnsis r primary medical nn-substance use that is related t a secndary substance use diagnsis within the year prir t enrllment. Individuals transitining with a histry f invlvement in children s services (e.g., RTF, HCBS, B2H waiver, RSSY). 1915(i)-Like Service Eligibility and Assessment Prcess: HARP members wh meet Targeting Criteria and Risk Factrs as well as Need-Based Criteria (belw), will have access t an enhanced benefit package f 1915(i) like Hme and Cmmunity-Based Services (HCBS). Need-based Criteria: Individuals meeting ne f the Needs-Based Criteria identified belw will be eligible fr 1915(i)-like services: An individual with at least mderate levels f need as indicated by a State designated scre n a tl derived frm the interrai Assessment Suite. An individual with need fr HCBS services as indicated by a face t face assessment with the interrai Assessment Suite and a risk factr f a newly-emerged psychtic disrder suggestive f Schizphrenia herein called individuals with First Episde Psychsis (FEP). Individuals with FEP may have minimal service histry. A HARP enrlled individual wh either previusly met the needs-based criteria abve r has ne f the needs based histrical risk factrs identified abve; AND wh is assessed and fund that, but fr the prvisin f HCBS fr stabilizatin and maintenance purpses, wuld decline t prir levels f need (i.e., subsequent medically necessary services and crdinatin f care fr stabilizatin and maintenance is needed t prevent decline t previus needs-based functining). All individuals in the HARP will be evaluated fr eligibility fr 1915(i)-like services. Once an individual is enrlled in the HARP, a Health Hme (r ther qualified individual cnsistent with the prvisin f cnflict free case management) will initiate an independent persn-centered planning prcess t determine a plan f care. This will include the cmpletin f a brief evaluatin fr 1915(i)-like eligibility. This prcess will cmply with federal cnflict-free case management requirements. Individuals determined eligible fr the 1915(i)-like services based n the brief evaluatin using the interrai will receive a cnflict-free functinal assessment frm an apprpriately qualified individual, Page 8 f 18

9 The assessment determines the medical and psychscial necessity and level f need fr specific HCBS services; ensures that inapprpriate, duplicative, r unnecessary services are nt prvided; and is used t establish a written, persn centered, individualized plan f care. Individuals initially identified as HARP eligible but nt currently enrlled in managed care will be referred t enrllment brker t help them decide which Plan is right fr them. Once enrlled in the HARP, members will have 90 days t chse anther HARP r return t a Mainstream MCO befre they are lcked int the HARP fr 12 mnths frm the date f enrllment (after which they are free t change Plans at any time). HARPs must ntify members f their Health Hme eligibility within a timeframe t be specified by the State. The Plans and Health Hmes will perate under the terms f the Administrative Health Hme Services Agreement and ther plicy and prgrammatic guidance that may be develped by NYS. Revised guidance regarding cllabratin between Plans and Health Hmes is being develped by the State with input frm the Health Plan Assciatins. 5. Cvered Services The MCO and HARP cntracts fr enrlled beneficiaries will cver all current physical health services and pharmacy benefits cvered under mainstream managed care. The MCO and HARP cntracts will cver Medicaid BH services including inpatient and utpatient hspital services and cmmunity-based rehabilitatin and clinic services. HARP cntracts will als cver the prvisin f 1915(i) Hme and Cmmunity Based Services. In first tw years f HARP peratin, the HARP capitatin payment will nt include 1915(i) Hme and Cmmunity Based Services. These will be paid n a nn-risk basis with the HARP acting as an Administrative Services Organizatin (ASO). NYS will prvide guidance fr Plans and prviders n 1915(i) Hme and Cmmunity Based Services. Guidance will be distributed prir t implementatin. Guidance will include: Service definitins Service cmpnents Service limits Admissin/Eligibility Criteria Page 9 f 18

10 Settings (Lcatin f Services) Prvider Qualificatins Billing prcedure cdes Service pricing NYS will develp a prcess fr State designatin f Hme and Cmmunity Based Service prviders. NYS anticipates that rehabilitatin services fr residents f cmmunity residences will be phased in t the capitatin rate in year tw. Cncurrent with the Demnstratin Amendment, NYS requested a State Plan Amendment (SPA) t mve SUD clinic services t the rehabilitatin ptin t prvide services in a mre recvery-riented mdel and t add residential SUD services t ensure that Medicaid individuals have a full array f SUD services available t them. Cst-sharing will be unchanged frm the current Medicaid FFS-apprved State Plan. There is n nminal Medicaid cst-sharing apprved in the State Plan fr mental health r SUD services. The Plan will ensure that the member is ffered all eligible benefits. Medicaid cvered services will be available thrughut the service area cvered by the Plan and prvided by the Plan s cntracted prviders, using the NYS Medicaid definitin f "medically necessary services". As part f the RFQ review prcess, Plans will need t submit their prpsed BH utilizatin review criteria t NYS fr review and apprval. All prpsed utilizatin review criteria (including State Plan rehabilitatin and 1915(i) waiver services) must be submitted n later than September 1, Fr all mdalities f care, the duratin f treatment will be determined by the member s needs and his r her respnse t treatment. All services, fr which a member is eligible, will, at a minimum, cver: The preventin, diagnsis, and treatment f health impairments; The ability t achieve age-apprpriate grwth and develpment; and The ability t attain, maintain, r regain functinal capacity. During the term f the cntract, the Plan may prvide cst-effective alternative services ( in lieu f ) that are in additin t thse cvered under the Medicaid State Plan as alternative treatment services and prgrams fr enrlled members under 42 CFR 438.6(e). The Plan must perfrm a cst-benefit analysis fr any new services it prpses t prvide, as directed by NYS, including hw the prpsed service wuld be cst-effective cmpared t the State Plan services. The Plan can implement cst-effective alternative ( in-lieu f ) services and prgrams nly after apprval by NYS. The Plan is encuraged t assist NYS t develp cst-effective alternatives fr services where it is beneficial t the recipient. MCOs may utilize telemedicine (including telepsychiatry) t the extent that it is medically apprpriate and cmplies with all State and federal requirements. Page 10 f 18

11 6. Rates All capitatin payments are subject t actuarially sundness per 42 CFR 438.6(c). Fr individuals enrlled in mainstream MCOs, a distinct BH rate calculatin will be applied fr each existing premium grup. Fr individuals enrlled in a HARP, NYS will establish an apprpriate premium grup and an integrated BH/PH capitatin payment will be determined. The HARP capitatin payment des nt include 1915(i) services in first tw years. Fr at least the first year f HARPs, the premium des nt include Health Hme payments. The HARP capitatin payment des nt include payment fr rehabilitatin services fr residents f cmmunity residences. Histrical eligibility, FFS claims and health plan encunter data were cnsidered in develping apprpriate base data fr rate setting during the initial rating perids. As health plan experience emerges and is deemed t be sufficiently credible and reasnable, the base data fr rate-setting will increasingly rely n actual health plan experience data. In rder t develp capitatin rates, the rate setting base data will be adjusted fr factrs including, but nt limited t: Prgram changes ccurring between the beginning f the base data perid and the end f the cntract perid. Utilizatin and unit cst trend between the base perid and the cntract perid. Differences in expected csts assciated with the transitin frm FFS t managed care and/r expectatins arund managed care efficiencies (as applicable). Nn-medical expenses, including csts assciated with administrative functins, care management and underwriting gain. Final capitatin rates will als be adjusted t accunt fr any applicable withhlds r risk sharing mechanisms that are a part f the prgram. New Yrk State will be replacing the current behaviral health stp-lss prgram fr Medicaid Managed Care with a psychiatric (MH) inpatient specific stp-lss prgram. SUD detx and inpatient rehabilitatin services will be included in the existing acute care inpatient stp lss prgram. 7. Perfrmance Standards Plans must meet the qualifying criteria in this RFQ t manage the delivery f Medicaid behaviral health services. This may be dne independently, r by subcntracting with a BH rganizatin. Plans are encuraged t Page 11 f 18

12 develp a gvernance mdel that includes the experience f their expanded behaviral health netwrk. Hwever, these relatinships cannt substitute fr the Plan requirements included in this RFQ. This dcument lists criteria that are in additin t present MCO requirements as delineated by the mdel cntract. These existing requirements remain in place and must be met unless explicitly mdified per this dcument. In the sectins that fllw, the requirements fr all managed care plans are specified. Additinal qualifying criteria must als be met t perate a HARP and administer the Hme and Cmmunity Based Services benefits (1915(i)-like benefits). These include: Cvered services NYS managed care rules Apprved BH UM criteria Apprved 1915(i) rules and requirements (fr HARPs) Prvider netwrks 24 hur, 7 days a week, 365 days a year persn staffed tll-free line t prvide crisis referral. BH netwrk develpment, care management, and prvider relatins activities. The Plan must demnstrate an adequate NYS presence f trained staff t ensure that BH netwrk develpment, care management, and prvider relatins activities are sufficient t accmplish Plan Behaviral Health Gals. BH cntracting, credentialing/re-credentialing. This functin may be lcated ut f state. BH prvider relatins with staff access t a claims reprting and payment reprting platfrm (claims may be administered at anther lcatin). BH utilizatin reviews with 24 hur, 7 days, 365 days a year a week access t apprpriate persnnel t cnduct prir authrizatin. Per federal guidelines, the MCO must respnd t prir authrizatin requests fr pst stabilizatin services within 1 hur (24 hurs a day).19 This service may be prvided ut-f-state but Plan staff must demnstrate knwledge f: Cvered services NYS managed care rules Apprved BH UM criteria Apprved 1915(i) rules and requirements (fr HARPs) BH care management cnsistent with requirements at 42 CFR (c). BH clinical and medical management Educatin and training n tpics required under this RFQ fr medical and BH prviders, State staff and ther member serving agencies, except fr specialized training where the Plan engages trainers with specialized expertise. Whenever pssible, training and educatin fr prviders shuld be prvided in crdinatin with the Reginal Planning Cnsrtiums (RPCs). BH resurces t assist with BH-specific quality management (QM) initiatives, financial versight, reprting and mnitring, and versight f any subcntracted r delegated functin. Page 12 f 18

13 The Plan must have an established technlgy platfrm that prvides technlgy supprt t cmply with requirements under this RFQ, including demnstrated success in: Data exchange with any business assciate that will perfrm activities required under the RFQ. Prvisin f web-based prtals with apprpriate security features that allw BH prviders and State agencies t submit and receive respnses t BH referrals, requests fr prir authrizatins fr BH services, and claims. Data-driven appraches t mnitr requirements described in the RFQ, by eligibility grup when apprpriate, including BH netwrk adequacy, crisis plans, psychiatric advance directives, and BH-specific reprting requirements fr UM, QM, and financial management as well as administrative and clinical perfrmance metrics. 8. Experience Requirements The Plan r its business assciate must have mre than five years f experience with Medicaid BH managed care prgrams. If a Plan is unable t demnstrate the experience required belw, it can hire an adequate cmplement f experienced staff r cntract with a Behaviral Health Organizatin. Plans chsing t hire experienced staff must submit the names, experience, and resumes f senir emplyees t be assigned t manage the BH benefit wh have the required expertise including a minimum f five years f experience in the areas required belw. Experience must include the fllwing: Demnstrated success with the implementatin f cmplex public sectr BH (managed care r fee-fr-service) prgrams in an efficient and effective manner. Plans will be expected t submit detailed infrmatin n the current management f their membership with BH needs, particularly thse with cmplex cnditins. Plans will be expected t describe their experience managing care fr ther high need ppulatins r cmplex benefits in NYS r elsewhere. Fr example: Managed Lng Term Care (MLTC) HIV SNP Hmeless Frensic BH Experience and demnstrated success with waiver services, peer supprts, r cmmunity rehabilitatin fr disabled ppulatins. Experience crdinating nn-medicaid funded care fr Medicaid BH service recipients including crdinatin with lcal, State, and federal/ther grant funded BH prgrams and supprts (e.g., Substance Abuse Preventin and Treatment and Cmmunity Mental Health Services Blck Grants). Page 13 f 18

14 Experience and demnstrated success in building and/r transfrming a netwrk delivery system t embrace principles f wellness and recvery, as demnstrated by: The develpment f a qualified culturally cmpetent prvider netwrk that emphasizes evidence-based and prmising practices. The incrpratin f the preferences f members and their families in the design f services and supprts (persn-centered care planning). The incrpratin f a hlistic apprach in the design and delivery f services and supprts, including assisting the member with btaining and maintaining stable, safe, permanent husing; meaningful emplyment; scial netwrks; and health and wellness. Cllabrating with cnsumer and/r family-run services, demnstrated by incrprating peer-run services int the prvider netwrk. The use f self-management and relapse preventin skills, Wellness Recvery Actin Plans (WRAPs), and psychiatric advance directives. Operating a utilizatin and care management prgram fr a cmprehensive array f BH prgrams and services similar t thse cvered under the cre benefit package described in this RFQ. Success includes a demnstrated reductin f inapprpriate admissins and readmissins t the emergency rm, inpatient, r ther 24-hur levels f care fr psychiatric r addictin disrders. Plans shuld describe their success in reducing behaviral health readmissins and increasing cnnectivity frm inpatient t utpatient services (bth BH and PH). Plans shuld prvide their current readmissin rates fr mental health inpatient and substance use rehabilitatin and detx. Plans shuld prvide their current utilizatin f the BH clinic and inpatient benefits. Experience in prviding services t ther Medicaid r gvernment-spnsred Plans fr members and ppulatins similar t the cvered members under this RFQ as demnstrated by: Expertise managing the full range f services fr individuals with primary r c-ccurring SUDs, including experience managing methadne and buprenrphine and ther addictin medicatins. Expertise with the management and versight f behaviral health pharmacy including plypharmacy, anti-psychtics, smking cessatin medicatins, and injectable antipsychtics. Expertise managing BH care fr special ppulatins including, but nt limited t adults with cccurring I/DD and/r chrnic medical cnditins r transitin-aged yuth. Experience and demnstrated success in implementing BH medical integratin as evidenced by dcumented imprvements in clinical and financial utcmes acrss the health care spectrum and cmmunicatin/crdinated Plan f care develpment between medical and behaviral prviders. Page 14 f 18

15 Experience in implementing BH-specific perfrmance imprvement prjects and valid, reliable perfrmance metrics, including examples f successful achievement f perfrmance threshlds r guarantees that embdy the system gals and perating principles utlined in this dcument. In additin t the abve minimum rganizatinal and experience requirements, Plans prpsing t manage a HARP prduct line must meet the fllwing requirements: The Plan r its staff shall have a prven track recrd in prviding services t Medicaid r ther gvernmentspnsred Plans fr members and ppulatins similar t thse described under the Hme and Cmmunity Based Services 1915(i)-like cmpnent f the Demnstratin Amendment as demnstrated by: Experience and demnstrated success managing BH care fr special ppulatins including, but nt limited t adults with SMI, adults with functinally limiting SUD, individuals experiencing a first episde psychsis, individuals with SMI and criminal justice invlvement, adults residing in permanent supprtive husing (PSH) r ther types f cmmunity husing and hmeless adults. Experience and demnstrated success in perating a cmprehensive care management prgram fr HARP like ppulatins. The Plan shall have a reasnable plan and sufficient internal resurces with the relevant expertise r plan t hire an adequate cmplement f experienced staff t custmize their technlgy platfrm t supprt cmpliance with federal HCBS requirements under the 1915(i)-like cmpnent f the 1115 waiver Demnstratin Amendment. This includes evaluating the adequacy f plans f care cmpared t assessed needs and that services are delivered cnsistent with the plan f care. A reasnable plan and sufficient internal resurces t review external functinal assessments, service eligibility determinatins, and plans f care fr SMI and/r SUD ppulatins. The Plan shall have a BH advisry subcmmittee (fr each regin crrespnding with RPCs) reprting t the MCO s gverning bard. The subcmmittee will include peers, prviders, lcal gvernment and ther key stakehlders. Experience in managing mainstream BH benefits, MLTC, HIV SNP, Hmeless, and Hme and Cmmunity Based waiver services fr nn-smi/sud ppulatins des nt in and f itself demnstrate the ability t manage care fr individuals with serius behaviral health disrders. Plans will be expected t prvide details n hw their experience qualifies them t manage BH benefits and netwrks in NYS, including HCBS benefits and netwrk prviders. Plans shall nte the unique challenges t wrking with individuals with serius behaviral health cnditins; lcal and system-wide barriers t effective care management; and their apprach t addressing these challenges and barriers. Plans will be expected t describe hw current prcesses and prcedures will be augmented r changed t meet the needs f peple with serius behaviral health cnditins. Page 15 f 18

16 Alternative Demnstratin f Experience: As stated abve, Plans that cannt demnstrate the required experience can: a) cntract with a Behaviral Health Organizatin (BHO); r b) recruit new Plan BH leadership, managers and staff with experience that meet the requirements abve. 9. Cntract Persnnel The purpse f these staffing requirements is t ensure the Plans have required BH, PH, pharmacy, utilizatin management, quality management, and care management expertise t meet the needs f individuals with mental illness, addictins, and c-ccurring physical health challenges. NYS expects that Plan staff will wrk as an integrated team with Health Hmes, prviders, and RPCs regardless f each Plan s rganizatinal structure. This sectin establishes minimum requirements fr key persnnel, managerial staff, and peratinal staff fr the Mainstream MCO and HARP prduct lines, including requirements fr staff t be dedicated t NYS Medicaid. 10. Netwrk Service Requirements The Plan s netwrk service area shall cnsist f the cunty(ies) described in the Plan s current Medicaid managed care cntract with NYS. Such service area is the specific gegraphic area within which eligible persns must reside t enrll in the MCO/HARP. Fr Plans applying t manage the behaviral health benefit in NYC (prir t the BH managed care state-wide rll ut), the netwrk service area cnsists f the city s five brughs nly. Plans must cntract with BH prviders utside the five brughs (e.g., Nassau, Westchester) if the prvider serves five r mre f the Plan s members. Members may chse the prvider they prefer frm a list f Plan cntracted prviders In establishing the netwrk, the Plan must cnsider the fllwing: Anticipated enrllment in Mainstream Plans and HARPs, and enrllment frm ther Plans; Expected utilizatin f services by the ppulatin t be enrlled; The number and types f prviders (including new BH prviders) necessary t furnish the services in the benefit package; The number f prviders wh are nt accepting new patients; The gegraphic lcatin f the prviders and enrllees. Page 16 f 18

17 The language and mbility/accessibility f prviders. In additin t the requirements in Sectin 21 f the MCO mdel cntract, the Plan shall: Develp a BH netwrk based n the anticipated needs f special ppulatins, including: Transitin age yuth with behaviral health needs Adults and transitin age yuth identified with First Episde Psychsis High risk grups such as individuals with SMI, c-ccurring majr mental disrders and SUDs and thse invlved in multiple services systems (educatin, justice, medical, welfare, and child welfare) Individuals with I/DD in need f BH services Individuals with a MH cnditin r a SUD and c-ccurring chrnic physical health cnditin Individuals with a SUD in need f medicatin-assisted treatment, including methadne and buprenrphine fr piid dependence Hmeless individuals Individuals in Supprtive Husing r ther types f cmmunity husing Adults transitining frm State Operated Psychiatric facilities and ther inpatient and residential settings Individuals with SMI/SUD transitining frm jail/prisn/curts Individuals in AOT status. Maintain a netwrk f physical health prviders that: Meets the physical health needs f peple with SMI/SUD. The netwrk f physical health prviders is expected t be the same fr the Mainstream MCO and the HARP; Prvides primary care screening fr depressin, anxiety, and SUD. T be cnsidered accessible, the netwrk must cntain a sufficient number and array f prviders t meet the diverse needs f the member ppulatin. This includes: Being gegraphically accessible (meeting time/distance standards), culturally cmpetent and being physically accessible fr peple with disabilities Prviding BH services fr members in their entire service area Ensuring a sufficient number f culturally cmpetent prviders in the netwrk t assure accessibility t benefit package services prvided by OMH r OASAS licensed prgrams and clinics and/r individual, apprpriately licensed practitiners Ensuring sufficient physical health netwrk capacity t meet the needs f peple with SMI and/r SUD Sufficient primary care prviders wh prvide screening fr depressin, anxiety disrders, and substance use with the capacity t treat r refer t apprpriate specialty prviders as necessary. Page 17 f 18

18 Minimum netwrk standards fr each service type are shwn in Table 3. Plans must meet the netwrk requirements in Sectin 3.5. If cntracting with required prviders des nt meet the minimum netwrk standards, the Plan must cntract with additinal prviders t meet the standard. Page 18 f 18