“ responsible change to achieve easy access, better quality and personal outcomes”
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Partnering for Success: The 1915 (b)/(c) Medicaid Waiver & DHHS Strategic Implementation Plan Update NC School Community Health Alliance Conference December 4, 2012 . Save Our Planet, Save Our Wildlife!. - PowerPoint PPT PresentationTRANSCRIPT
1 “Responsible Change to Achieve Easy Access, Better Quality and Personal Outcomes”
Presentation by: Kathy Nichols, DMA Mabel McGlothlen, DMH
Save Our Planet,Save Our Wildlife!
Partnering for Success:The 1915 (b)/(c) Medicaid Waiver
& DHHS Strategic Implementation
Plan Update
NC School Community Health Alliance Conference
December 4, 2012
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Priority of DHHS, DMA & DMHDDSASStart Date:July 1, 2010
Expansion Completion
Date:July 1, 2013
o Building success upon successo Improving quality and effectivenesso Increasing accountability for all stakeholderso Contain Medicaid Costo Increasing consumer/family/stakeholder
confidence in the MH/DD/SA provider networko Priority tasks:
o 1915 b/c Waiverso Provider Quality
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The Vision
1915 B/C Medicaid
Waiver
The State
CAP-MR/DD
WaiverOverarching Goal:
To successfully provide easily accessible, high quality,
cost effective MH/DD/SA servicesand supports that result in person-centered outcomes for
individuals served.
Building success one step at a time.
2010 20122011 2013 Future
Provider Quality
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DHHS 1915 b/c Waiver Goals
Start Date:April 2009
RFA Selection
Date:July 1, 2010
1. Improve access to MH/DD/SAS Services.2. Improve quality of MH/DD/SAS Services.3. Improve outcomes for people receiving
MH/DD/SAS Services.4. Improve access to primary care for people
with mental illness, developmental disabilities and substance abuse.
5. Improve cost benefit of services.6. Effectively manage all public resources
assigned to the MCOs.
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DMHDDSAS Reform & DMA Waiver History
History:2001
2010
2001 – State Plan 2001: Blueprint for Change (41 APs)
2003 – LMEs Local Business Plan submissions… PBH 2005 – Through DMA, CMS awarded PBH, the right to
administer and manage a State 1915 b/c waiver as a pilot project for the delivery of publicly funded MH/DD/SA services operating in Cabarrus, Davidson, Rowan, Stanly, and Union Counties.
April 2009 – Legislative Report Medicaid Waivers for LMEs S.L. 2008-0107 Section 10.15(y)
In May 2009 – The Secretary requested that DMH and DMA develop a 1915 b/c Medicaid waiver amendment for Statewide waiver expansion, replicating PBH’s waiver, for submission to CMS by Dec. 15, 2009
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First Round of Request For Applications (RFA’s)
Start Date:April 2010
RFA Selection
Date:July 2010
SESSION 2009, SL-2010-31 / SB 897; Section 10.24
RFA Process, the State can select two waiver entities; PBH cannot expand; complete a Legislative Report;
Legislative Report: an evaluation: I/DD consumers survey and ICF-MR Facility Impact
RFA Applications received – April 2010 Mecklenburg, Western Highland Network,
Sandhills Center and ECBH.
DHHS RFA Announcement Selection – July 2010
Mecklenburg and Western Highland Network
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Session Law 2011 – 264, House Bill 916
Start Date:
July 1, 2011
Expansion Completion
Date:
July 1, 2013
House Bill 916 ECBH and SHC allowed to go forward Waiver
Implementation plans based upon original application
PBH allowed to expand /cancelling SB 897 (SB316) New LME population requirements 300K – 2012 /
500K – 2013 (consistent with RFA requirements) By October 1, 2011 submit a strategic plan
delineating specific strategies and agency responsibilities for the achievement of statewide expansion of the 1915 (b)/(c) Medicaid Waiver.
RFA Selection Announcement by August 2011 DHHS – January 2013 / July 2013 – Complete
unassigned LME Programs.
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Second Round RFA
Start Date:
July 1, 2011
Expansion Completion
Date:
July 1, 2013
RFA Applications Submission – May 2011 PBH Expansion Notice (A-C, Five County, OPC) CenterPoint; Durham Center (Johnston,
Guilford, Cumberland); Eastpointe (Beacon, SER); Pathways (MHP, Crossroads); Smoky Mountain; Southeastern Center (Onslow-Carteret); and Wake County
July 26th - Successful Application Reviews: Eastpointe; Pathways; and Smoky Mountain
RFA Applications resubmission / Final Selection
Durham Center – July CenterPoint and Southeastern Center –
November
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Final LME-MCO Merger MapLocal Management Entity - Managed Care Organizations (LME-MCOs)
and their Member Counties (Current and Proposed on January 1, 2013)
Anson
Ashe
Avery
Beaufort
Bertie
Bladen
Brunswick
Burke
Cabarrus
Caldwell
Carteret
Catawba Chatham
CherokeeClay
Cleveland
Columbus
Craven
Currituck
Forsyth
Gates
Graham
Granville Halifax
HarnettHenderson
Hertford
Jackson
Jones
LeeLincoln
Macon
Madison
MontgomeryMoore
Nash
Northampton
Onslow
Pamlico
Pender
Pitt
Polk
Robeson
Rockingham
Rowan
Rutherford
StokesSurry
Swain
Union
Vance
Wake
Warren
Watauga Wilkes
Wilson
Yancey
For proposed LME-MCOs that have not yet merged, the lead LME name is shown first. Sandhills Center and Guilford are scheduled to merge on January 1, 2013.
● Dates shown through July 2012 are actual Waiver start dates. Dates after July 2012 are the planned Waiver start dates.● Reflects plans and accomplishments as of October 12, 2012.
Orange
Transylvania
Person
Western Region Central Region Eastern Region
Cumberland
Scotland
Haywood
NewHanover
Durham
Alleghany
Alamance
Iredell
Johnston
DuplinSampson
Wayne Lenoir
Dare
Hyde
Martin TyrrellWashington
Camden
PerquimansPasquotank
Greene
Smoky Mountain Center Jul 2012
AlexanderMitchell
Gaston
Buncombe
CenterPoint Human Services Jan 2013
Caswell
Chowan
Edgecombe
Western Highlands NetworkJan 2012
McDowell
Alliance Behavioral Healthcare/Johnston/ Cumberland
Jan 2013
CoastalCareFeb 2013
Guilford
Randolph
East Carolina Behavioral Health Apr 2012
EastpointeJan 2013
MeckLINK Behavioral HealthcareFeb 2013
Cardinal Innovations Healthcare Solutions(All counties as of Apr 2012)
Partners Behavioral Health Management Jan 2013
Stanly
DavieFranklin
HokeRichmond
Mecklenburg
Yadkin
Davidson
Sandhills Center Dec
2012/ GuilfordApr 2013
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LME-MCO Implementation Time Line
GOALS:1. Improve access to
MH/DD/SAS Services.
2. Improve quality of MH/DD/SAS Services.
3. Improve outcomes for people receiving MH/DD/SAS Services.
4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse.
5. Improve cost benefit of services.
6. Effectively manage all public resources assigned to the MCOs.
IMPLEMENTATION / Start Date Time lines…. Phase I
PBH - AC – Oct. 2011; 5 Cty – Jan. 2012; OPC – Apr. 2012 WHN - January 2012 ECBH - April 2012
Phase II Smoky Mountain - July 2012 SHC - December 2012
Guilford County Merger January 1st / Waiver of GC: April 1st.
Phase III – Implementation completed by January / July 2013
Alliance (Durham/Wake) / CenterPoint / Eastpointe (BC/SER) / Partners (PW/CR/MHP) / *Mecklenburg / *CoastalCare (SEC/ OC)
* reflects potentially a February 1st start date. DHHS – assigns unassigned catchment areas – January 2013 DHHS Process to be finalized by July 2013. POST IMPLEMENTATION January / July 2013….
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What is a Medicaid Waiver
Medicaid Waiver -
101 DMA (Medicaid) gets a 1915b/c waiver
from CMS (Centers for Medicare & Medicaid)
The waivers allows DMA to let a managed care company (LME) run the Medicaid program for mh/sa/dd services in their counties.
Allows DMA to offer HCBS (habilitation) “Mini Medicaid Program” DMA monitors the LME-MCOs to make
sure that they follow all Medicaid rules.
CMS monitors DMA
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Medicaid Waiver Goals Improved Quality of Care Increased Cost Benefit Predictable Medicaid Costs Combine the management of State/Medicaid Service Funds
at the Community Level Increased consistency, efficiency and economies of scale in
the management of community servicesSupport the purchase and delivery of best practice services Ensure that services are managed and delivered within a
quality management framework Empower the LME-MCO to build partnerships with
consumers, providers and community stakeholders with the goal of creating a more responsive system of community care.
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What does the LME-MCO do for Medicaid?
Enroll & monitor providers (statewide) Call Center—Customer Support, expansion of STR Make sure consumers with greatest need get connected
to providers and have treatment plans (Care Coordination)
Authorize “medically necessary” services Pay for mh/sa/dd services Provide education about ALL Medicaid benefits to
recipients & consumers (website, mailings, seminars) Reviews, Medications Care Management, OAH Hearings
(Due Process) Gap analysis/community development CCNC collaboration
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Medicaid “Care Coordination for Special Health Care Needs” vs.
Targeted Case Management
Care Coordination (42 CFR 438.208(c)) I/DD (eligible for Innovations) Innovations waiver recipient Adult SPMI & LOCUS score Child SED & CALOCUS score Substance Dependence & ASAM level Opioid Dependent & IV-use Dual Diagnosis & LOCUS/ASAM level
Identify Assure Treatment Plan exists Assure access to all assessments & specialists Episodic & Time-limited
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CCNC & LME-MCO Collaboration CCNC = NC Health Home LME-MCO is vital partner that supports Health
Home Shared Care Management of recipients
Identification, linkage to services Coordination of MH/SA/DD & physical health
needs Data exchange into Informatics Collaboration on integrated care practices Monthly-quarterly partnership meetings Care Coordination = health promotion = cost
savings
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Provider Concerns in a 1915 b/c Waiver Limited Provider Network Care Coordination inside the MCO LME rate negotiation capacity (Note: higher rates can
be paid to address access concerns) Expanded service authorization function Loss of direct enrollment in State Medicaid Program
(contract with LME) Loss of State level cost reporting/cost finding Inclusion in larger system of care (e.g. community ICF-
MR facilities)Note: Some concerns can be addressed in the DMA and DMHDDSAS Waiver Contracts signed by the LME-MCO
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What else does DMA require of the LME – MCO ?
They must hire disability-specific specialists Psychiatrists Psychologists I/DD Qualified Professionals Licensed mental health professionals (LCSW, LPC) Licensed substance abuse professionals (LCAS)
Robust Quality Management Process Provider & consumer involvement
DMA, DMHDDSAS, and two external vendors monitor the LME-MCO — monthly, quarterly, yearly (on all operations)
EQRO Annual Review
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1915 b/c Waiver “At-Risk” Benefits
They can develop their own Utilization Management (UM) criteria, Level of Care (LOC), Length Of Stay (LOS)
They can do “care management”— have clinical discussions with providers
Use the Treatment Authorization Request (TAR) but they can ask for additional information
Limit their provider network (after initial offer of contract to all Medicaid providers)
Pay differential rates—for specialty care, for crisis services, for performance; can use case rates or sub-capitation
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1915 b/c Waiver “At-Risk” Benefits
“ Extra Services ” : b3 Services Projected savings from better management of care &
network Inpt, ED use, LOS in residential treatment, pay for
outcomes Supports Intensity Scale (SIS)*
Extra services that benefit the population PBH: robust array (mature network) New LME-MCOs
Respite* (children, Innovations waitlist) Community Guide (Innovations waitlist) Peer Support Services (MH/SA consumers)
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Waiver Supports Intensity Scale (SIS)
Approved by CMS for use in NC SIS used for planning purposes (AAIDD)
Used to develop funding levels currently in the following States: OR, CO, LA, GA, WA, RI, & 2 Canadian provinces;
In process for development to use for purposes to determine funding levels: NC, UT, MA, ME, ND
**CAP MR/DD services crosswalk to Innovations services = web posting…
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CCNC—NC Health Home CCNC is the Health Home for NC Medicaid recipients. CCNC is responsible for the following for patients with
“chronic conditions*”: Comprehensive care management Care coordination/health promotion Comprehensive transitional care Patient and family support Referrals to community and social support services Use of HIT to link services
*including serious/persistent mental illness and substance abuse disorders
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CCNC—NC Health Home Behavioral Health Initiatives
14 Psychiatrists in Regional Networks Teach PCPs to address MH/SA issues in primary care Teach PCPs to collaborate with behavioral health
providers Use brief screenings
Ex. Screening, Brief Intervention, and Referral to Treatment (SBIRT)
MDD education and treatment Atypical antipsychotic programs for children Training CCNC care managers and PCPs in
Motivational Interviewing
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Health Homes and Specialty Behavioral Health
CCNC (Community Care of NC) will be NC’s Health Home Model with the LME/MCO to address the behavioral health needs through the 1915 b/c waiver
Much work has been done to interface the data sharing and to clarify the roles/responsibilities of LME/MCOs and CCNC
Four Quadrant Care Management Model Determines who takes the lead in care management Quadrants 1 and 3 – CCNC/Primary Care take lead Quadrant 2 – LME/MCO/Behavioral Health take lead Quadrant 4 – flexible sharing of responsibilities
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CCNC Four Quadrant Care Management Model
Quadrant I:
Low MH/DD/SA health
Low physical health complexity/risk
Quadrant II:
High MH/DD/SA health
Low physical health complexity/risk
Quadrant III:
Low MH/DD/SA health
High physical health complexity/risk
Quadrant IV:
High MH/DD/SA health
High physical health complexity/risk
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CCNC Health Homes & LME - MCOs
LME/MCOs provide care management for individuals with SPMI and substance use “chronic conditions”
LME/MCOs formed a collaborative relationship with
local CCNC networks
LME/MCOs signed data-sharing agreements with the CCNC Informatics Center
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Waiver Strategic Plan Report
The Waiver Strategic Plan Report is an initial guide to monitor LME/MCO waiver implementation and takes us through the dates of January 2013.
The report is considered an initial plan that will evolve and be modified over time, experience, and with LME and stakeholder involvement.
The Department through DMH/DD/SAS and DMA will monitor, evaluate and report the progress quarterly per legislative requirements.
Web link to the report….http://www.ncdhhs.gov/mhddsas/providers/1915bcWaiver/waiver1915b-cplan-final10-19-11.pdf
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Waiver Strategic Introduction – Continued:
GOALS:1. Improve access to
MH/DD/SAS Services.
2. Improve quality of MH/DD/SAS Services.
3. Improve outcomes for people receiving MH/DD/SAS Services.
4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse.
5. Improve cost benefit of services.
6. Effectively manage all public resources assigned to the MCOs.
The Strategic Implementation Plan:
Is organized around a framework encompassing the State’s vision for the Waiver initiative and goals.
Is based on an assessment of strengths and the challenges that lie ahead.
Will provide a vehicle for active communication with all stakeholders across the State and for coordinating detailed implementation tasks among the Department, DMA, DMH/DD/SAS, LMEs, providers and consumers, and family members.
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Pre-Implementation Plan Process for LMEs
GOALS:1. Improve access to
MH/DD/SAS Services.
2. Improve quality of MH/DD/SAS Services.
3. Improve outcomes for people receiving MH/DD/SAS Services.
4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse.
5. Improve cost benefit of services.
6. Effectively manage all public resources assigned to the MCOs.
PRE – Implementation Monitoring Phase of LME-MCOs reporting out on their implementation activities
IMT’s (Intra-Departmental Monitoring Team) Agenda: Report out of all of the LME-MCO function
areas of development… Aggregate IMTs /// Think Tank IMTs
Two Readiness reviews State & Contract Agent
CMS Approval.
The DHHS Executive Monitoring Team (EMT) including representatives from multiple stakeholder groups provided review and feedback
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Post-Implementation Process for LME-MCOs
GOALS:1. Improve access to
MH/DD/SAS Services.
2. Improve quality of MH/DD/SAS Services.
3. Improve outcomes for people receiving MH/DD/SAS Services.
4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse.
5. Improve cost benefit of services.
6. Effectively manage all public resources assigned to the MCOs.
POST - Implementation Phase IMT EQRO – DMA vendor goes to the LME. 6 months of on-going monthly monitoring
IMTs Annual Reviews
Positive Improvement POC Industry Standard Recommendations…. EBP
Services Feedback built into a plan of correction Quarterly IMTs EMT
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Evaluation Process, Continued:
Additional mechanisms to evaluate the Waiver implementation process and ensure the quality of the service system, include, but are not limited to:
External Quality Review (EQR) Intra-departmental Monitoring Teams (IMTs) Annual On-site Reviews Performance Measures Executive Management Team (EMT) Global Continuous Quality Improvement DMH/DD/SAS Quality Improvement Steering
Committee
The REAL Start Date:Jan 1, 2013
CQI Date: On-going !
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“Responsible Change to Achieve Easy Access, Better Quality and Personal Outcomes”
Plan
ActEvaluat
e
Improve
The LME-MCOs managing the 1915 b/c Waivers will continue to evolve and be modified over time with continued stakeholder involvement striving for quality and improvement of the mh/dd/sas system.
WAIVER GOALS:1. Improve access to
MH/DD/SAS Services.
2. Improve quality of MH/DD/SAS Services.
3. Improve outcomes for people receiving MH/DD/SAS Services.
4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse.
5. Improve cost benefit of services.
6. Effectively manage all public resources assigned to the MCOs.
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Thank you…
Plan
ActEvaluat
e
Improve
Questions / Thoughts / Comments….