florida medicaid reform · 2006-06-30 · 3 medicaid reform is not reform will not change who...

Florida Medicaid ReformBehavioral Health

Broward County

June 29, 2006

Overview of Florida Medicaid Reform

Gail WilkField Office Manager

Medicaid Area 10

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Key Elements of ReformNew Options / Choice:

– Customized Plans.

– Opt-Out.

– Enhanced Benefits.

Financing:

– Premium Based.

– Risk-Adjusted Premium.

– Comprehensive and Catastrophic Component.

Delivery System:

– Coordinated Systems of Care (PSN and HMOs).

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Medicaid Reform is Not

Reform will NOT change who receives Medicaid.Reform will NOT “cut” the Medicaid budget. The budget will continue to grow each year.Reform is NOT connected with Medicare Part D.The state will NOT limit medically necessary services for pregnant women or children.The state has NOT asked to waive Early and Periodic Screening Diagnosis and Treatment (EPSDT) for children.The state will NOT increase cost sharing requirements.

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Mandatory Population(Current Managed Care Eligibles)

Beginning in Duval and Broward Counties:

– Temporary Assistance for Needy Families (TANF).

– TANF-Related Group:

• Low income single parent families.

• Low income families with a disabled or unemployed parent.

– Aged and Disabled (not receiving Medicare).

– Specialty Populations:

• Children with Chronic Conditions.

• HIV / AIDS Patients (Capitated Plans).

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Voluntary Populations

The following individuals, eligible under the groups below, will be excluded from mandatory participation during the initial phase:

– Foster care children / adoption subsidies.

– Individuals diagnosed with developmental disabilities.

– Pregnant women with incomes above the TANF poverty level.

– Individuals with Medicare coverage (dually eligible).

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Excluded Populations

Medically Needy population.

Aliens receiving emergency assistance.

Enrollees diagnosed with breast and cervical cancer.

Individuals enrolled in the following programs:

– Family Planning Waiver,

– Hospice and Institutional Care,

– Residential commitment programs / facilities operated through the Department of Juvenile Justice (DJJ),

– Residential group care operated by the Family Safety & Preservation Program of the DCF.

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Excluded Populations (continued)

Individuals enrolled in the following programs:

– Children's residential treatment facilities purchased through the Substance Abuse and Mental Health District Offices of the DCF (also referred to as Purchased Residential Treatment Services - PRTS),

– Substance Abuse and Mental Health residential treatment facilities licensed as Level I and Level II facilities,

– Residential Level I and Level II substance abuse treatment programs, and

– Florida Assertive Community Treatment Team (FACT).

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Covered ServicesPlan Design Guidelines

– EPSDT and other services to children.

– Maternity care and other services to pregnant women.

– Physician and physician extender services.

– Hospital inpatient care.

– Emergency care.

– TransPlant services.

– Medical/drug therapies (chemo, dialysis).

– Family Planning.

– Outpatient surgery.

– Laboratory and radiology.

– Transportation (emergent and non-emergent).

– Outpatient mental health services.

Required at least to current State Plan levels:

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Covered ServicesPlan Design Guidelines (continued)

Required and tested for sufficiency:

– Hospital outpatient services.

– Durable medical equipment.

– Home health care.

– Prescription drugs.

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Covered ServicesPlan Design Guidelines (continued)

Required to be offered, but amount, scope and duration are flexible:

– Chiropractic care.

– Podiatry.

– Outpatient therapy.

– Adult dental services.

– Adult vision services.

– Adult hearing services (hearing aids and related services offered at State Plan level).

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Additional ServicesAt Plan Option

(Examples)

Over-the-counter medications.

Adult preventive dental.

Acupuncture.

Respite Care.

Nutrition Counseling.

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Choice Counseling Vendor Requirements

Ensure the choice counseling process and related material are designed to provide counseling through face-to-face interaction, by telephone, in writing and through other forms of relevant media.Provide flexibility in approach to effectively reach all Medicaid populations.Require the contractor to hire choice counselors who are representative of the State's diverse population and to train choice counselors in working with culturally diverse populations.Promote health literacy and provide information to reduce minority health disparities throughout outreach activities for Medicaid recipients.

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Vendor Procurement

Agency released Invitation to Negotiate on December 28, 2005.

Deadline for Receipt of Responses February 20, 2006.

Negotiations April 3 - 12, 2006.

Agency selected Affiliated Computer Services (ACS).

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Status UpdateFlorida State University Contract

Develop educational and outreach materials:

– Materials to be mailed to recipients.

– Outreach DVDs.

– Other items as needed.

Focus groups used in development of materials.

Develop Choice Counselor Certification program.

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Enrollment Timeline for Current Medicaid Beneficiaries

Overall, a 7 month phase in beginning September 1, 2006.

– Uncommitted MediPass Population - phased in over 7 months (1/2 in September 2006, then 1/6th in each of the next six months).

– PSN Population - phased in evenly over 3 months, beginning October 2006.

– HMO Population - phased in 1/12th of their enrolled population for 3 months, starting in October then 1/4th each month, beginning January 2007.

Florida Medicaid Reform

Behavioral Health Services

Carol Barr-PlattMedical Health Care Program Analyst

Bureau of Managed Health Care

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Medicaid Reform Behavioral Health Services

Application Review Process – Plan Readiness.

Service Provision.

Provider Requirements.

Continuity of Care.

Pharmacy Services.

Reimbursement.

Grievance.

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Medicaid Reform Behavioral Health Services Application Plan Readiness

Information Provided to the Bureau of Managed Health Care for Desk Review:

– BH Policies and Procedures (based on Contract).– Provider Network Listing.

– Provider Directory.

– If services are Subcontracted:

• Provide copies of Subcontracts with MBHO.

– Model Contracts with Individual Providers, Groups, Facilities, and CMHC’s.

– Copy of Health Plan and MBHO Organizational Chart.

– Quality Improvement Program Description.

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Medicaid Reform Behavioral Health ServicesApplication Plan Readiness (continued)

Information Provided to the Bureau of Managed Health Care for Desk Review (continued):

– Utilization Management Program Description.– Behavioral Health Member Handbook.– Behavioral Health Provider Handbook.– Model Notification Letter to Enrollees.– Model Notification Letter to Contracted Providers.– Plan’s Training Process for Providers: Claims,

Authorization, etc.– Credentialing File Review, including Specialty

Information. (selected files)– On-Site Reviews will be scheduled as needed.

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Medicaid Reform Behavioral Health Services Health Plan Requirements

Medicaid Reform Health Plans:– Shall comply with all current Florida Medicaid

Handbooks including but not limited to:• Mental Health Targeted Case Management Coverage

and Limitations Handbook, • Community Behavioral Health Services Coverage and

Limitations Handbook, and• Hospital Inpatient Handbook.

– Shall comply with the limitations and exclusions in the Florida Medicaid Handbooks unless otherwise specified in the Contract.

– Must furnish services up to the limits specified by the Medicaid Program, pursuant to 42 CFR 438.210(a).

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Medicaid Reform Behavioral Health Services Health Plan Requirements (continued)

Medicaid Reform Health Plans:– Shall provide the full range of those behavioral health

care services authorized under the State Plan and specified by this Contract.

Contractually Required Services Include:– Inpatient Hospital Services.– Outpatient Hospital Services.– Physician Services.– Community Mental Health Services.– Mental Health Targeted Case Management.– Intensive Case Management.

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Medicaid Reform Behavioral Health ServicesHealth Plan Requirements (continued)

Medicaid Reform Health Plans are not contractually required to provide:– Sub-Acute Inpatient Psychiatric Program (SIPP).– Behavioral Health Overlay Services (BHOS).– Specialized Therapeutic Foster Care.– Therapeutic Group Care Services.– Substance Abuse Services (except as required by

Contract).– Residential Care.– Clubhouse Services (fee-for-service)– Comprehensive Behavioral Assessment.– Florida Assertive Community Treatment Team (FACT)

Services.

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Medicaid Reform Health Plan Behavioral Health Quality Improvement Responsibilities

The Health Plan shall monitor and evaluate the quality and appropriateness of care and service delivery (or the failure to provide care or deliver services) to Enrollees through:Performance Improvement Projects (PIP’s)– Two PIP’s are required for Behavioral Health.– Each PIP must include a statistically significant sample

of Enrollees.– The Health Plan must submit their description (s) of

each PIP to the Agency for approval within 3 months of execution of contract.

– The PIP’s must be completed in a reasonable time period to allow for evaluation of the information.

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Medicaid Reform Health Plan Behavioral Health Quality Improvement Responsibilities

(continued)

Medical/Clinical Record Audits.

Performance Measures.

Surveys, and related activities.

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Medicaid Reform Health Plan’sBehavioral Health Provider Requirements

The Plan shall ensure that it has Providers that are qualified to serve Medicaid Beneficiaries and experienced in serving severely emotionally disturbed children and severe and persistent mentally ill adults.

All documentation shall be contained in the Providers’credentialing file.

The files must document the education, experience, prior training and on-going service training for each staff member or individual Provider and Areas of Specialty.

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Medicaid Reform Health Plan’s Contracting for Behavioral Health Services

The Health Plan shall enter into agreements with the CMHC or centers in each county and agencies funded pursuant to chapter 394, Part IV, F.S., regarding coordination of care and treatment of enrollees jointly or sequentially served.

The Agency shall approve all Model agreements between the Health Plan and its Providers.

This requirement shall not apply if the health plan has made good faith efforts and no agreement is reached.

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Medicaid Reform Health Plan’s Contracting for Behavioral Health Services

(continued)

The Health Plan shall solicit behavioral health care service Providers that are currently serving members to join the Network. An exception to this must be made in writing to the Agency.

To the maximum extent possible, the Health Plan shall contract for the provision of BH Services with Community Mental Health Centers designated by the Agency and DCF.

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Medicaid Reform Behavioral Health ServicesTransition Plan

The following applies only to Enrollees who were enrolled in either a PSN, MediPass, or an HMO which was not previously providing Behavioral Health Services in either Broward or Duval Counties.

– A transition plan is defined as a detailed description of the process of transferring enrollees from Providers to the Health Plan’s behavioral health care provider network to ensure optimal continuity of care.

– The plan must include, but not be limited to, a timeline for transferring enrollees, description of provider medical record transfers, scheduling of appointments, proposed prescription drug protocols, and claims approval for existing providers during the transition period.

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Medicaid Reform Behavioral Health ServicesTransition Plan (continued)

The Plan will be required to minimize the disruption of treatment by an enrollee’s use of service outside of the Health Plan’s Network.

For enrollees who have been receiving behavioral health treatment for at least six months from a behavioral health care Provider, whether or not the Provider is in the Health Plan’s network or not, the Health Plan will continue to authorize all valid claims until the Health Plan reviews the Enrollee’s treatment plan and implements an appropriate written Transition Plan.

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If the previous treating provider is unable to allow the Plan access to the Enrollee’s clinical record because the Enrollee refuses to release the medical record, then the Health Plan shall approve the Providers claims for:

– four sessions of individual or group therapy,

– one psychiatric medical session,

– two one-hour Intensive Therapeutic On Site Sessions, and

– six days of Day Treatment Services.

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During the first 3 months that the Enrollee receives Behavioral Health services under this contract the Health Plan shall not deny requests for Behavioral Health services outside the Network under the following conditions:

– Enrollee is a patient at a community health center and the center has discussed the enrollees care with the Health Plan.

– If, following contact with the Health Plan, there is no Behavioral Health Care Provider readily available and the enrollee’s condition would not permit a delay in treatment.


Behavioral Health ServicesPharmacy Services

Sybil RichardAssistant Deputy Secretary for

Medicaid Operations

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Pharmacy Services

The Medicaid Reform Plan:

– shall make available those drugs and dosage forms currently covered by the Medicaid Program.

– shall not arbitrarily deny or reduce the amount, duration, or scope of prescriptions solely because of the diagnosis, type of illness, or condition.

– may place appropriate limits on prescriptions based on criteria such as medical necessity or for the purpose of utilization control, provided the services can reasonably be expected to achieve the purpose set forth in the State Plan.

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Pharmacy Services (continued)

The Plans shall make available those drugs and dosage forms listed in the Preferred Drug List.

– The Bureau of Managed Health Care requires the Plans to submit their drug formulary for behavioral health.


Behavioral Health ServicesProvider Reimbursement

Melanie Brown-WoofterAHCA Administrator

Health Systems Development

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Provider Reimbursement

The Health Plan shall approve claims from Providers for authorized out of Plan non-emergent services, provided such claims are submitted within twelve months of the date of service. (Section VI, J. 5 Medicaid Reform Health Plan Contract)

The Plan must process such claims within the time period specified in 641.31555, F.S.

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Grievances

Any disputes related to coverage of services necessary for the transition of Enrollees from the current behavioral health care provider to the Behavioral Health Care Provider shall follow the process set forth in Section IX, Grievance System of the Medicaid Reform Health Plan Contract.

The Health Plan must develop, implement and maintain a Grievance System that complies with federal laws and regulations, including 42 CFR 431.200 and 438, Subpart F, “Grievance System”.

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Grievances (continued)

The Grievance system must include a Grievance Process, Grievance Resolution, Appeal Process, Resolution of Appeals, Post Appeal Resolution, Expedited Process Medicaid Fair Hearing System and Post Medicaid Fair Hearing Decision process. (The PSN can not go to the Subscriber Assistant Program. They will have a separate Panel which is current being developed.)

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florida medicaid reform · 2006-06-30 · 3 medicaid reform is not reform will not change who...

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