NYAPRS Note: Congratulations again to the NYS Council's successful effort to require state government to show the legislature that transition plans to roll behavioral health services and dollars into integrated managed care plans will demonstrate network adequacy, responsiveness and positive outcomes, as well as extending the APG rates 2 more years into 2017.New York Providers See Success in Bill Language To Monitor BH Services Mental Health Weekly April 1, 2013
As New York state prepares its transition into a Medicaid Managed Care environment, members of its provider community have reason to celebrate.
New York lawmakers have accepted new budget language to require state health officials to monitor access to behavioral health services to ensure network provider adequacy and timely care. The new bill language would also extend by one year the proposed phase-out date of ambulatory patient group (APG) reimbursement rates.
The implementation of New York state's public behavioral health system into managed care follows recommendations by the state's Medicaid Redesign Team, convened by Gov. Andrew M. Cuomo in January 2011, to find ways to increase quality and efficiency in the Medicaid program and reduce cost (see MHW, Feb. 14, 2011).
The New York State Council for Community Behavioral Healthcare worked with government relations consultants to draft new language in the Senate and Assembly's budget bill (Final Health Article VII) that would include a study to review the impact of managed care on consumers with mental health and substance abuse disorders.
The Council pressed for a provision in the budget bill that would require the New York State Department of Health, in conjunction with the Office of Mental Health (OMH) and the Office of Alcoholism and Substance Abuse Services (OASAS), to conduct a "performance metrics" study. This analysis would inform providers whether recipients are being served in a timely way, close to home and by a "robust network" of specialty providers who understand their needs, said Lauri Cole, executive director of the NYS Council for Community Behavioral Healthcare.
"A performance metrics study would tell us how the system is functioning and whether clients are getting what they need in a reasonable time frame," Cole told MHW. "Our proposal asked the government to ensure that special needs plans and Behavioral Health Organizations (BHOs) have an adequate network of qualified providers available to meet the treatment needs of individuals seeking outpatient clinic services."
Cole added, "We are grateful to the members of the Senate and Assembly for recognizing the impact of managed care."
According to the legislation, in selecting managed care contractors, state health and behavioral health officials would ensure that any contractor or contractors have an adequate network of providers to meet the behavioral health and health needs of enrollees, and review the adequacy prior to approval of any such contract or contracts, and upon contract renewal or expansion.
Additionally, the legislation stipulates that on or before Aug. 31, 2016, health and behavioral health commissioners will submit a report to the Senate and Assembly leaders that will include recommendations on how to preserve adequate levels of service with a focus on quality of care and rate adequacy under managed care plans.
MMC payment rates New language in the budget bill includes a provision relating to a 2010 mandate that increased Medicaid payments to providers through managed care organizations and providing equivalent fees through an ambulatory patient group (APG) methodology.
The governor had proposed a sunset date - a measure within a statute that provides that the law will cease to take effect after a specific date - for the APG payment rate in 2015.
However, before they did that, providers felt it was important there be a study or evaluation of some critical data as the state transitions into managed care, said Cole. Cole said the Council wanted to ensure continued access to care for Medicaid Managed Care (MMC) beneficiaries.
Initially, the push for an increase in MMC care rates began in 2009. The Council led an effort to secure a commitment from the governor to raise the MMC rates being paid to OMH outpatient providers, said Cole. "We did this because the rate was on average between one-quarter to one-half of the Medicaid fee-for-service rate at that time and our members were dropping their contracts with MMC companies due to insufficient reimbursement," Cole said.
Ultimately, APG government rates were enacted in the 2010 state budget, she said. This was supposed to bring reimbursement for MMC services on par with the Medicaid fee-for-service rate; however, it was not implemented until the fall of 2012, she said.
"In the meantime, mental health clinics continued to fall through reimbursement cracks, with some going out of business or giving back their licenses to the state," she said. "We saw this as an emergency requiring intervention by the state."
Patients, meanwhile, had a significant wait time for an appointment for services in the publicly funded outpatient treatment system. Some of them "simply gave up and stopped requesting care," she said.
"The problem with this is that many of these same individuals will wind up receiving treatment in a more acute and costly care setting as a result of a mental health crisis or substance-abuse-related emergency." Cole added, "It just makes more sense to have that care available to those who need it when they need it so intervention can occur early in the disease process, thereby minimizing risk to the client and saving the state money."
Not wanting to see this circumstance occur again during the early days of the transition and implementation of behavioral health managed care, the Council lobbied for the APG government rates to continue until data regarding the overall health of the outpatient system could be collected and analyzed.
"The administration wanted to phase out the government rates in 2015; however, we understood that moving our continuum of care to managed care and destabilizing the rates shortly thereafter was too much of a risk," Cole said.
"The transition will be very challenging," said Cole. "We are concerned with ensuring network adequacy and access to and continuity of care during the [managed care] transition. Dropping the rates within one year of the transition would have put care recipients in jeopardy, and so we pressed hard to push back the phase-out date of APG government rates." The NYS Council succeeded. The APG rates will expire on March 31, 2016, according to the legislation.
"Stabilizing the rate during a period of significant transition is critical to protect consumers and to ensure care will be available as needed by the New Yorkers who need these services the most," she said. *