NYAPRS Note: In January 2011, Governor Cuomo called for extensive changes in New York’s Medicaid system to improve service access, quality and outcomes and to reduce cost. A Medicaid Redesign Team was appointed and various specialty work groups were created to craft the details as to how redesign would be developed in those areas. The MRT’s Behavioral Health Work Group has been meeting since June 2011, with staff support from OMH, OASAS, DOH and the NYC Department of Health and Mental Health. For more details about the group and their previous findings, see http://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health_reform.htm.
At this past Wednesday’s meeting, the staff issued design materials to integrate behavioral health care into managed care systems per the Work Group’s previous discussions and recommendations; those materials were posted this morning on our website at www.nyaprs.org.
NYAPRS is very pleased to see a number of items we have worked for in these designs, most notably the enhanced recovery focused benefit package and outcome targets, the focus on reinvesting all first year savings into enhanced, improved services and that peer services are included in both the benefit package and outcome measures (their definitions will need to be clarified and enhanced). Advocates are looking to work with the state to ensure that appropriate advance information is provided to beneficiaries and that adequate mechanisms to advance beneficiary rights and choice protections are in place.
Here is NYAPRS’s summary of key points contained in those materials. Stay tuned for further analysis and also for more details as to how stakeholders can provide feedback to the state on these designs.
Over the course of 2014 (by April in NYC and by October elsewhere), currently ‘carved out’ Fee for Service OMH and OASAS services will be integrated into managed care plans that can demonstrate their capacity to meet “rigorous” state standards, either on their own or in partnership with a “qualified” Behavioral Health Organization.
Those services include
- OMH/OASAS mental health and substance abuse inpatient and clinic services
- OMH Medicaid services like PROS, ACT, IPRT, ACT, CDT, Partial Hospital, CPEP, Targeted Case Management and rehab supports within community residences and
- OASAS Medicaid services like Opioid treatment and outpatient chemical dependence rehabilitation.
- Rehabilitation supports for Community Residences
Health and Recovery Plans (HARPs)
- The state is also creating special needs Health and Recovery Plans, which will not only provide the above services but will be expected and funded to provide a range of more intensive services for individuals with ‘significant behavioral health needs’.
- HARPs will get more funding to provide these enhanced services and will have to meet higher quality, access and network standards and care coordination expectations.
- HARPs are expected to fully integrate these behavioral health services with physical health, pharmacy, long term care and health home services.
- Mainstream plans can be approved to operate HARPs by themselves if they meet ‘rigorous’ state standards. Such plans may also choose to partner with a BHO to meet those standards.
The extended, more intensive benefits will include services that the federal Medicaid agency (CMS) has allowed states to adopt via the 1915.i Home and Community Based Services option (something NYAPRS has vigorously advocated for since its inception). Those services include:
- Services in Support of Participant Direction: Information and Assistance in Support of Participant Direction and Financial Management Services
- Crisis: Crisis Respite
- Support Services: Community Transition, Family Support, Advocacy/ Support and Training and Counseling for Unpaid Caregivers
- Empowerment Services: Peer Supports
- Service Coordination
- Rehabilitation: Pre-vocational, Transitional Employment, Assisted Competitive, Employment, Supported Employment, Supported Education, Onsite Rehabilitation, Respite and Habilitation
All plans (HARPs or not) applying to carve in the OMH/OASAS services must demonstrate their capacity to offer person centered individual plans of care and care coordination that will extend to ‘non plan services’ like housing. Such plans will also have to demonstrate that they can interface with “social service systems to address homelessness, criminal justice, and employment related issues’ and interface with Local Governmental Units (LGU) and state psychiatric centers.
Initial HARP Eligible Population - Mental Health
- Medicaid Enrolled
- Initially, over 20 years of age as of 2011 (Qualifying service use prior to 21st birthday is considered in qualification.)
- Could add individuals 18-21 based on functional assessment and diagnosis
- e.g., first episode psychosis
- Non Medicare enrolled ("dual enrollee") in the 2009-2011 period
- Not eligible for OPWDD managed care
- SMI diagnosis
Other Criteria for HARP Eligibility
- SSI or SSI/MA only and at least one "organized" mental health Medicaid fee-for-service or Medicaid managed care service in 2011.
- SSI individuals who did not meet the qualifications and non-SSI individuals who met the “Minimum HARP Qualifications” if they met one of the following qualifications:
- Received three or more claims for ACT, TCM, PROS, or PMHP services in any of the 2009-2011 years
- Received more than 30 days of psych inpatient services in any of the last 3 years
- Had three or more psychiatric inpatient admissions in the three years 2009 through 2011 with at least one admission in 2011
- Were discharged from an OMH PC after an inpatient stay greater than 60 days in last year
- Had a current or expired AOT ("Assisted Outpatient Treatment") order in 2008-2011
- Were discharged from NYS Department of Corrections with a history of inpatient or outpatient treatment through OMH's Central NY Psych Center in 2008-2011
- Were residents in OMH funded Housing for persons with serious mental illness in any of the 2009-2011 years
HARP Eligible Population - Substance Use
- 2 or more detoxification admissions (inpatient/outpatient) within 12 months (CY 2011)
- 1 inpatient rehabilitation admission within 12 months (CY 2011)
- 2 or more inpatient hospital admissions with primary substance use diagnosis or with SUD related DRG and a secondary substance use diagnosis within 12 months (CY 2011)
- 2 or more emergency department visits with primary substance use diagnosis or primary non-substance use/related secondary substance use diagnosis within 12 months (CY 2011)
Future pathways to HARP enrollment
- Individual identified based on functional/clinical assessment
- Individual identified by the Local Governmental Unit (LGU)
- Individuals would still need to be functionally assessed
- Periodic review of historical Medicaid utilization
According to the data presentation, the average per person per month state expenditures for behavioral health services for HARP eligible beneficiaries in 2011 was about $2,500, or $30,000 annually for those who maintained Medicaid eligibility and HARP enrollment over the 12 month period. Non HARP beneficiary BH monthly spending in 2011 came in at around $2,258.
The design is intended to “assure reinvestment of savings in services and supports for people with behavioral health needs.”
Raising Standards for Behavioral Health Care
The state is intending to “raise the bar on behavioral health management for all members” and will look for applicants to demonstrate “expertise and experience, network, access, service utilization/ penetration, care coordination”, ability to engage the disengaged and to promote ‘consumer engagement’ (engagement by peers?).
The state will offer financial incentives for plans that meet identified performance standards and will expect applicants to demonstrate a plan to reinvest savings to improve service delivery.
The state will develop measures well beyond the current ‘HEDIS’ standards which, for behavioral health, are currently limited to measuring if hospital dischargees get to outpatient visits within 7 days and fill prescriptions within 30 days. Such measures will include increased access, service engagement and physical health improvements.
HARP measures will include measures around Home Care Coordination/Engagement and recovery measures relating to the provision of extended “1915(i)-like services” like:
- participation in employment;
- enrollment in vocational rehab services and education/training;
- housing status;
- community tenure;
- criminal justice involvement;
- peer service use and
- improving functional status
These measures will require indicators beyond those current available by looking at Medicaid claims and encounter data and may need to be phased in.
The state will issue a Request for Qualifications (RFQ) that will require plans, on their own or in partnership with a qualified BHO, to demonstrate how they are or will be capable manage currently carved-out services and, if desired, to meet the enhanced HARP standards.
Plans applying to develop HARPS will have to be additional program and clinical requirements and “must cover all counties that their mainstream Plan operates in.”
- Program design finalized: Spring 2013:
- Contract Requirements for MCOs, HARPs finalized: Summer 2013
- New York City RFQ posted on website for at least 30 days in NYC: Late Summer 2013
- Qualified MCOs and HARPs are selected in NYC: Winter 2013
- RFQ posted on website for upstate groups: Winter 2013
- HARPs, MCOs are operational in NYC: Spring 2014
- Qualified MCOs and HARPs are selected for upstate: Summer 2014
- HARPS, MCOs are operational upstate: Fall 2014
Children’s MCOs, HARPs go live in Spring 2015