CA’S MEDICAID WAIVER RENEWALS

UPDATE AND HIGHLIGHTS RELEVANT TO THE PUBLIC BEHAVIORAL HEALTH

SYSTEM

PRESENTATION TO CBHDA ALL MEMBERSMARCH 12, 2015

Molly Brassil Director of Public Policy

County Behavioral Health Directors Association of California

OVERVIEW 1915(b) Waiver Renewal – Specialty Mental Health

Consolidation 1115 Waiver Renewal – “Medi-Cal 2020”

DSRIP 2.0 Behavioral Health Project Behavioral Health Incentive Proposals Whole Person Care Pilot Other

Drug Medi-Cal Organized Delivery System Demonstration Questions & Discussion

MEDICAID WAIVERS Medicaid Waivers allow:

The federal government to waive specified provisions of Medicaid Law (Title XIX of the Social Security Act).

Flexibility and encourage innovation in administering the Medicaid program to meet the health care needs of each state’s populations.

Social Security Act sections allowing authority of waivers: Section 1115: Research and Demonstration Projects Section 1915(b): Managed Care/Freedom of Choice Section 1915(c): Home and Community Based Services

1915(B) VS. 1115 Section 1115 Waivers

Allows for waiver of broad scope of Medicaid rules, including eligibility criteria, benefit packages, service delivery and payment

Allows states flexibility to design demonstration projects that promote the objectives of the Medicaid program, extend coverage to populations who would otherwise not qualify for Medicaid, permits federal matching funds for state costs that are not standard program rules

Section 1915(b) Waivers Allows states to implement managed care delivery systems, or

otherwise limit individuals’ choice of provider May not be used to expand eligibility to individuals not eligible

under the approved Medicaid state plan Cannot negatively impact beneficiary access, quality of care of

services, and must be cost effective

1915(B) WAIVER – SPECIALTY MENTAL HEALTH CONSOLIDATION

Section 1915(b)(4) Waiver (Managed Care / Freedom of Choice) Waives Freedom of Choice, Statewide-ness and Comparability of

ServicesBeneficiaries must receive services through a MHP in their

countyAll MC beneficiaries are enrolled in the SMHS Waiver and have

access to services provided through the waiver if they meet described medical necessity criteria

Section 1915(b) waivers re: to specialty MH services have been in effect in CA since 1995

Waiver has been approved for 2-year periods, state must submit renewal apps to continue waiver

Current term is July, 1 2013 – June 30, 2015

1915(B) RENEWAL APPLICATION Section A – Program Description. Describes the delivery system,

geographic areas served, populations services, access standards, quality standards and program operations (marketing, enrollee rights, grievance system, etc.)

Section B – Monitoring Plan. Describes the monitoring plan for the upcoming waiver term, including the monitoring of QI efforts.

Section C – Monitoring Results. Describes monitoring results from the most recent waiver term.

Section D – Cost Effectiveness. Projects waiver expenditures for the upcoming waiver term.

PROPOSED UNIFORM STATEWIDE ACCESS MEASURES

1) Percentage of non-urgent mental health services (MHS) appointments offered within 10 or 15* business days of the initial request for an appointment

2) Number and percentage of acute psychiatric discharge episodes that are followed by a psychiatric readmission within 30 days during a one year period. The year is defined as Jan 1-Nov 30

3) Percentage of acute (psych inpatient and PHF) discharges that receive a follow up outpatient contact (face to face, phone or field) or IMD admission within 7 days of discharge

4) Percentage of acute (psych inpatient and PHF) discharges that receive a follow up outpatient contact (face to face, phone or field) or IMD admission within 30 days of discharge

5) Percentage of TARs approved or denied within 14 calendar days of receipt

CA’S SECTION 1115 “BRIDGE TO REFORM” DEMONSTRATION WAIVER

The Demonstration Approval Period for CA’s Section 1115 Bridge to Reform Demonstration Waiver is 11/1/10 – 10/31/15

The current waiver includes several initiatives to prepare CA for ACA implementation, including (but not limited to): Low Income Health Program Delivery System Reform Incentive Pool (DSRIP) Safety Net Care Pool Various managed care transitions (SPDs, rural expansion, HFP) Optional Medi-Cal Expansion Coordinated Care Initiative

Waiver renewal request must be submitted to the Centers for Medicare and Medicaid Services (CMS) at least 6 months before the end of the current Demonstration (October 31, 2014)

DHCS initiated a stakeholder process over Fall 2014 / Winter 2015 to develop a renewal proposal (supported by foundations)

DHCS CORE STRATEGIES FOR WAIVER RENEWAL

Core Strategy #1: Shared Savings Proposal. Seeking a $15-20B fed investment in the waiver’s comprehensive approach to delivery system alignment and innovation

Core Strategy #2: Delivery System Transformation and Alignment Incentive Programs DSRIP 2.0 targeted at public safety net systems Regional incentives for MCOs, County BH, providers FFS QI incentives Workforce development Access to housing and supportive services Whole person care pilots

Core Strategy #3: Payment and Delivery System Alignment for Public Safety Net Systems. Transform CA’s public safety net for the remaining uninsured by unifying DSH and SNCP funding streams into a county-specific global payment system.

PUBLIC HOSPITAL DSRIP 2.0 PROPOSAL Successor DSRIP would continue to stabilize the public hospital

and health system through quality improvement and population health advancement

Successor program would be more standardized with a heavier emphasis on outcomes and value-oriented requirements through promotion of the triple aim (quality, health, cost).

Five Domains:1) Delivery System Transformation2) Care Coordination for High Risk, High Utilizing Populations3) Resource Utilization Efficiency4) Prevention5) Patient Safety

DSRIP 2.0 PROPOSALPROPOSED BEHAVIORAL HEALTH

PROJECT Domain 1, Project 1.4 – Integration of Physical and Behavioral Health Goals include:

Identify BH diagnoses early Ensuring treatment for medical / BH conditions are compatible and do not

cause adverse effects Improve medical and BH outcomes for patients with chronic medical

conditions Objectives include:

Increase use of screening tools Patient adherence to treatment Increase access to BH treatment Reduce preventable acute care utilization Improve communication between PCP and BH Reduce admissions Improve patient experience

DHCS STRAW PROPOSAL FOR BEHAVIORAL HEALTH INCENTIVE

PROGRAM Goal to incentivize improved system-level coordination between MHPs /

DMC and MCPs beginning with critical infrastructure development for info exchange and development of med management protocols.

Shared savings pool available for MCPs plans and MHPs (SUD) to jointly promote care integration and better outcomes for adults who meet med necessity criteria for MC Specialty MH Services / DMC.

Initial Pool funded by DHCS to incentive achievement of early process measures before savings are realized.

Desired outcomes include practice of integrated care plans and other evidence of improved collaboration, improved medication adherence, reduced emergency department visits.

Build upon strategies in Cal MediConnect.

BH PROVIDER INCENTIVES / P4P Team-based integrated care model with tiered care coordination

services for mild/moderate/severe mental health needs

Care coordination or co-location approach

Incentive design could include:

Supplemental payments for care coordination tiered based on acuity

P4P payments for achievement of quality, integration, and health equity goals

Shared savings structure that incentivizes use of an integrated care model

Could be complemented by a health home program

WHOLE PERSON CARE PILOTS PROPOSAL

County / Regional pilots to focus on “high utilizers of multiple systems” as identified through shared data

Pilots would test innovative care coordination strategies across multiple local systems (health/MH/SUD, social services, etc.) and allow additional flexibility for allocation of resources / information exchange

A key component envisioned is to be authorized through the waiver to receive federal funds for services not traditionally covered by the Medicaid program, such as targeted housing assistance.

DRUG MEDI-CAL – ORGANIZED DELIVERY SYSTEM WAIVER PROPOSAL

Waiver Goals / Overview Continuum of care modeled after ASAM criteria (common standard for

assessing needs, optimizing placement, documentation, etc.) Enables more local control and accountability, greater administrative

oversight and quality control Emphasis on EBPs, coordination with other systems such as MCPs and

criminal justice Terms and Conditions / County Readiness

Delivery System (County operated / opt-in) Benefits and Levels of Care (Required and Optional, Residential Services) Quality Assurance / Program Integrity

Priority Considerations Provider Certification Federal financial participation Non-federal share of cost / Rate-setting

Questions &

Discussion

CBHDA CONTACT

Molly Brassil, MSWDirector of Public Policy

County Behavioral Health Directors Association of California(916) 556-3477, ext. 1152

mbrassil@cbhda.org