introduction & housekeeping · introduction & housekeeping • children’s system training...

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Introduction & Housekeeping • Children’s System Training and Technical Assistance to date (MCTAC and CTACNY)

• Housekeeping

• WebEx Chat Functionality for Q&A • Slides are posted at MCTAC.org and a recording will be available soon (usually less

than one week) • Questions not addressed today will be re-visited during subsequent presentations

• Reminder: Information and timelines are current as of the date of the presentation

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Transforming the Children’s Medicaid System Part 2 of 3 – Overview Thursday, February 11, 2016 12:00 - 1:00 pm Angela Keller, LMSW Director, Bureau of Children’s Program Policy, Design & Planning Division of Managed Care NYS Office of Mental Health

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Agenda • Welcome • Goals & Key Features of Children’s Design • Medicaid Basics • More Information: New State Plan Services & HCBS Benefits • Upcoming MCTAC Webinar & Offerings • Discussion + Q&A

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The GOAL is to… Get children in receipt of Medicaid back on their developmental trajectory:

-Identify needs early -Maintain the child at home with support and services -Maintain the child in the community, in least restrictive settings -Prevent longer term need for higher end services

Focus on recovery

and building resilience!

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Children and their families receive the right services, at the right time, in the right amount.

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Key Features of Children’s Medicaid Redesign Initiative Transforming the Delivery of Heath Care for Children

• The State continues to develop many details of the Design • Expanding access to care management for children with chronic conditions

under the Health Home program, or for children with lesser needs through Managed Care plans or other vehicles – a key to integrating care planning and service provision – September 2016

• Creating New State Plan Services – January 2017 • Transitioning existing children’s behavioral health benefits from fee-for-

service to managed care – a key to integrating behavioral health and physical health - January/July 2017

• Providing greater access to an aligned array of Home and Community Based Services, beginning in 2017

• Shifting the voluntary foster care “per diem” population to managed care, January/July 2017

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NYS Medicaid Basics

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What Could Make a Child Eligible for Medicaid Today? • Child’s family’s income is below specific thresholds based on household size • Child meets specific disability requirements • Child’s family spends down a required amount of medical expenses each month • A child is adopted and may be eligible to continue Medicaid eligibility.

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Two Payment Systems for NYS Medicaid Services 1. Medicaid Managed Care System – a managed care organization authorized by NYS

receives a monthly premium from NYS Medicaid for an enrolled individual and manages the individual’s care within a specific comprehensive benefit package. The Plan assumes risk, provides care management and applies utilization management methods for each member. When providers in the Plan’s network (i.e., hold a contract with the Plan) provide a service to the individual, the provider bills the Plan and is paid funds from the premium.

2. Fee-for-Service Delivery System – a provider is authorized by NYS to deliver a Medicaid service. If delivered to a Medicaid enrolled individual, the provider bills Medicaid through the eMedNY billing system. NYS pays the provider directly through eMedNY, for each Medicaid service delivered.


TODAY – Examples of Medicaid Services that Medicaid Managed Care Pays for Children • Physical health services (e.g., visits to pediatrician, vaccinations,

diagnostic tests, screening) • Dental care services (e.g., teeth cleaning, tooth extraction,

treatment of cavities) • Behavioral and physical health inpatient care (i.e., hospital level of

care) • Mental Health Outpatient Clinic Services (i.e., those designated to

serve both adults and children)


TODAY – Examples of Medicaid Services for Children that are Paid by NYS through the Fee-for-Service Payment System and are Carved out of Medicaid Managed Care OMH Residential Treatment Facility (RTF) OASAS Residential Services for Youth OASAS Outpatient Services Home & Community Based Services (HCBS) under 1915(c) Waivers of

OMH, OCFS and DOH OMH Outpatient Clinics with special designation to serve children with

Serious Emotional Disturbance (SED) OMH Day Treatment


Medicaid Eligible Populations Excluded from Medicaid Managed Care Today • Children with Third Party Health Insurance (i.e., parent has employer offered health insurance or insurance

coverage through the Exchange)

• Children dually eligible for Medicaid and Medicare

• Individuals who become eligible for Medicaid only after spending down a portion of their income

• Children placed in voluntary foster care homes

• Youth placed in OCFS operated Juvenile Justice facilities

• Enrollees of Child Health Plus

• Children of Native American Tribes

• Eligible individuals served by Office for People With Developmental Disabilities (OPWDD) – OPWDD Medicaid Redesign is Separate Initiative

Some children can be eligible for Medicaid but be excluded from Medicaid Managed Care, and still be eligible for certain Medicaid services which would be paid out of the fee-for-service payment system.

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Services for Medicaid Eligible Children Today - 2016 Tomorrow –Full Managed Care

Implementation

• All Services in Medicaid Managed Care

• Current Behavioral Health State Plan Services Fee-for-Service

• Limited Array of HCBS Services (depending on Waiver program) available only to Waiver eligible Children through Fee-for-Service System

• Care Coordination Under 1915c Waivers and OMH TCM Program through Fee-for-Service System

• Current Behavioral Health State Plan Services in Medicaid Managed Care

• Health Home Care Coordination – available to significantly expanded population of children

• Foster Care Population transitions to Medicaid Managed Care

• Six New State Plan Services created and transition to Medicaid Managed Care

• Expanded array of HCBS Services based target and functional criteria transitions to Medicaid Managed Care


Michael Michael’s Medicaid services are paid by Medicaid Managed Care Plan, who in turn pays providers for • Dental Check Up • Pediatrician Visits for well-

care and treatment of illness • Medications

Michael lives with his mother and two siblings. He is eligible for Medicaid due to the household income and is enrolled in a Medicaid Managed Care Plan.

TODAY

Michael’s Medicaid services will all be paid by a Medicaid Managed Care Plan with premium dollars, directly to providers: • Dental Check Up • Vaccinations • Testing and Treatment for

Strep Throat • Services in an OMH

designated SED clinic • Psychosocial Rehabilitation • Health Home Care

Coordination • HCBS Skill Building • HCBS Respite

2017 and Beyond - Transition to MMC

Michael has additional Medicaid services paid through NYS Fee-for-Service Payment System • HCBS services through the OMH

SED Waiver • Services in an OMH designated

SED clinic


New Children’s Medicaid State Plan Services


Children’s Medicaid State Plan Amendment - Update

• Six New Services: Crisis Intervention, Other Licensed Practitioner, Community Psychiatric Supports and Treatment (CPST), Psychosocial Rehabilitation, Family Peer Support Services and Youth Peer Support Services

• SPA Application - in final revision stage; projected to be submitted to CMS in April 2016

• The State Proposed 2016-17 Budget Includes new investments of $7.5 million and $30 million in 2017-18 for the six new Medicaid State Plan services

• SPA Provider Manual – in draft pending CMS approval of the children’s SPA; draft projected to be released in February

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Children’s SPA Provider Identification Process • Anticipate an application and designation process – late Spring or

after • Must hold specific types of licenses, certifications or designations

from OMH, OASAS, OCFS or DOH and serve children • Technical assistance will be given to those that are not already

Medicaid providers • The State will provide guidance on MMIS Provider enrollment for

designated providers • Approximately 6 months prior to launch, MCTAC will offer service

specific training

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Coming Soon: Draft SPA Provider Manual

• Definition of Service Components • Allowable Service Modality • Allowable Setting • Admissions/Discharge Criteria (i.e., medical necessity) • Limitations/Exclusions • Agency/Supervisor/Practitioner Qualifications • Training Requirements and Recommendations • Recommended Staffing Ratio/Caseload Size

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Home and Community Based Services (HCBS) Benefits


Medicaid Managed Care Transition • State interagency team is progressing on 1115 application draft

for CMS • Request for Qualification (RFQ) for Medicaid Managed Care

Plans to be developed, in order to qualify plans to manage all children’s benefits

• HCBS Provider Manual under development • HCBS Rates under development • Revisions to Managed Care Model Contract to be developed, to

detail children’s specific implementation requirements for Medicaid Managed Care Plans to follow


Alignment of the five 1915(c) Children’s HCBS Waiver under one array of HCBS benefits beginning in 2017

• Habilitative Skill Building

• Caregiver/Family Supports and Services

• Prevocational Services

• Supported Employment

• Community Advocacy and Training

• Non-Medical Transportation

• Habilitation

• Respite (Crisis & Planned)

• Adaptive and Assistive Equipment

• Accessibility Modifications

• Palliative Care (includes Family Palliative Care Education, Bereavement, Massage and Expressive Therapy, and Pain and Symptom Management)

• Care Coordination (for children ineligible for or opting out of Health Home)

Requires CMS Approval of 1115 Demonstration for Medicaid Managed Care

1915c Waiver Programs will be discontinued at the completion of the transition

Expanded eligibility for HCBS will be phased in beginning in 2017 and eligibility include targeting and functional criteria

HCBS will be paid in Medicaid Managed Care and Medicaid Fee-for-Service system (for children in Medicaid and excluded from Managed Care)

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Current Children’s HCBS Providers within 1915c Waivers • Will be grandfathered and designated to provide the HCBS via letter,

requiring attestation and agreement • If children’s providers are designated to provide adult HCBS benefits to

HARP enrollees, they will be grandfathered in this process as well • If grandfathered and designated children’s HCBS providers wish to provide

additional HCBS benefits, they will apply for additional designation via an application

• Once designated, a list of providers will be given to Medicaid Managed Care Plans – at that point contracting can commence (providers will be informed and technical assistance available)

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Building Capacity: Additional Children’s HCBS Providers

• An application process will be developed • Once designated, a list of providers will be given to

Medicaid Managed Care Plans – at that point contracting can commence

• For those providers who are not Medicaid providers, technical assistance will be provided to facilitate this process


Training and Technical Assistance

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Upcoming Offerings Register now for Part 3 of series at mctac.org:

• Part 3: Building Capacity and Preparing for Changes Ahead Thursday, February 25th, 12:00 – 1:00 pm Identifying areas that providers will have to build knowledge/capacity around. Outlining training & technical assistance plans for the year.

Lessons learned from the NYC adult system transition. Reminder: slides and recordings from the series will be available via MCTAC.org. Questions can be sent in advance to [email protected].

mailto:[email protected]

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Upcoming Offerings (cont.) • In-depth transformation update events presented by state agency children’s leadership team

for executive/senior leadership of child-serving OMH, OASAS, DOH and OCFS providers. • 3/21 Long Island (PM) • 3/22 New York City (AM & PM offerings) • 3/31 Poughkeepsie (PM) • 4/1 Albany (AM) • 4/12 Buffalo (AM) • 4/13 Finger Lakes (AM) • 4/14 Syracuse (AM)

• Technical assistance will be offered for SPA, HCBS, and Managed Care transition including high-level topic introductions and in-depth implementation guidance


MCTAC Tools & Resources • Materials from Adult Managed Care Training Series • Glossary, top acronyms, managed care language guide,

matrix, FAQ • Stay current on the NYS DOH Website

http://www.health.ny.gov/health_care/medicaid//program/medicaid_health_homes/health_homes_and_children.htm

• More to come!

Preliminary Resources and Information

http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/health_homes_and_children.htm

http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/health_homes_and_children.htm


Questions? NYSOMH Managed Care Mailbox [email protected] NYSDOH Health Homes for Children [email protected] and/or Managed Care Technical Assistance Center [email protected]



introduction & housekeeping · introduction & housekeeping • children’s system training...

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