August 28, 2015

1. August 28, 2015

2. Agenda Purpose of Behavioral Health Managed Care Transition Behavioral Health (BH) Managed Care Program Design and Timeline State Plan and Behavioral Health Home and Community Based Services (BH HCBS) BH HCBS Designation Status Health and Recovery Plan (HARP) Enrollment and Assessment Rest of State RFQ Questions Received to Date

3. Medicaid Redesign Team: Objectives • Fundamental restructuring of the Medicaid program to achieve: • Person-centered recovery oriented care • Measurable improvement in health outcomes • Sustainable cost control • More efficient administrative structure • Better integration of care

4. Why we need to transform care: • The 30-day readmission rate for NYC is 25% and 20% for Rest of state. • Outpatient Mental Health (MH) or Substance Use Disorder (SUD) treatment within 7 days of discharge is 35% for NYC and 42% for Rest of State. • Two or more Mental Health (MH) outpatient visits within 30 days of discharge in NYC is 32% and 40% for Rest of State.

5. Why we need to transform care: BHO Phase 1 post-discharge outcomes for Substance Use Disorder (SUD) discharges, CY 2012 • 45-Day readmission rate for NYC is about 45% and about 18% for Rest of state. • Lower level of SUD service or MH outpatient care within 14 days of discharge is about 31% for NYC and 48% for Rest of State. • Three or more SUD lower level services within 30 days of discharge in NYC is 20 % and 35% for Rest of State.

6. Integrated Care: In BHO Phase I, how often did behavioral health inpatient providers identify general medical conditions requiring follow-up, and did they arrange aftercare appointments? Based upon 56,167 statewide behavioral health community discharges (all service types) January 2012—June 2013

7. Federal Approval of Behavioral Health Managed Care Design July 2015 – NYS received CMS approval for the 1115 Waiver Amendment expanding behavioral health services in Medicaid Managed Care.

8. Principles of BH Benefit Design • Person-centered care management • Integration of physical and behavioral health services • Recovery oriented services • Patient/Consumer Choice • Ensure adequate and comprehensive networks • Tie payment to outcomes • Track physical and behavioral health spending separately • Reinvest savings to improve services for BH populations • Address the unique needs of children, families & older adults

9. Behavioral Health Managed Care Design • Behavioral Health will be managed by: • Managed Care Organizations (MCO) meeting rigorous standards (perhaps in partnership with a Behavioral Health Organization (BHO)) • All Plans MUST qualify to manage newly carved inbehavioralhealth services and populations • Plans can meet State standards internally or contract with a BHO to meet State standards • HARPs for adults with significant behavioral health needs • MCOs may choose to apply to operate a HARP product with expanded benefits • HIV SNPs will include HARP benefits for eligible members

10. Health and Recovery Plan Medicaid Managed Care Plan MMC Plan vs. HARP • Medicaid eligible adults • Specialized integrated product line for people with significant behavioral health needs • Eligible based on utilization or functional impairment • Enhanced benefit package - All MMC covered benefits PLUS access to HCBS to help individuals meet their goals (employment, independent living, education, etc.) • Specialized medical and social necessity/ utilization review for expanded recovery-oriented benefits • Benefit management built around higher need HARP patients • Enhanced care coordination - All may be in Health Homes • Performance metrics specific to higher need population and BH HCBS • Integrated medical loss ratio Medicaid Eligible Benefit includes Medicaid State Plan covered services Organized as Benefit within Managed Care Organization (MCO) Management coordinated with physical health benefit management Performance metrics specific to BH BH annual expenditure minimum

11. Adult Rest of State (counties outside NYC) Behavioral Health Managed Care Timeline • September 18, 2015 – MCOs submit ROS Adult RFQ application (Full and Expedited Versions) • November 2015 – Anticipated MCO conditional designation • Mid-November 2015 – Individual NYS/MCO RFQ follow-up discussion • December-March 2016 –Readiness Reviews (Desk Audit/On-site) • April-June 2016 – Final MCO Designation and HARP Certificate of Authority • July 2016 – Mainstream and HARP behavioral health management begins

12. Implementation Schedule of the Key Elements of Children’s Medicaid Redesign Plan (the “How”)

13. Expansion of Behavioral Health in Medicaid Managed Care The expansion of BH in Medicaid managed care is two-pronged: • Benefit Expansion • BH services expanded for MMC enrollees • HARP implementation

14. Substance Use Disorder (SUD) and Mental Health (MH) State Plan Services-Adults MMC Covered BH Services for all enrollees: • Inpatient – SUD and MH • Clinic – SUD and MH • Personalized Recovery Oriented Services (PROS) • Intensive Psychiatric Rehabilitation Treatment (IPRT) • Assertive Community Treatment (ACT) • Continuing Day Treatment (CDT) • Partial Hospitalization • Comprehensive Psychiatric Emergency Program (CPEP) • Opioid treatment • Outpatient chemical dependence rehabilitation • Rehabilitation Services for Residents of Community Residences (Not initially in the benefit package)

15. Expansion of BH Services in Services Medicaid Managed Care Benefit Package Expanded services are available to all Medicaid Managed Care enrollees • Mental Health Services • Licensed Mental Health Practitioner Services (Off-site services that may only be provided by OMH licensed clinics) • Behavioral Health Crisis Intervention • Substance Use Disorder Services • Residential Redesign - Three phases: OASAS Intensive Residential, Community Residential, Supportive Living and Medically Monitored Detox • Reassignment of SUD clinic to State Plan “Rehab Option” to permit off-site delivery of services

16. HARP, Health Home and BH HCBS • All HARP members will be offered Health Home care management services • All HARP members will be annually assessed for eligibility for BH Home and Community Based Services. • The Community Mental Health (CMH) suite of the interRAI has been customized for NYS and includes: • Brief Assessment to determine HARP and BH HCBS eligibility • Full Assessment to identify needs and assist in the development of a care plan • Health Homes will conduct the NYS Community Mental Health Assessment • Health Homes will develop person-centered care plans that integrate physical and behavioral health service, include BH HCBS • HARPs will need to approve Health Home plans of care to comply with HCBS conflict-free requirements

17. Individual Employment Support Services • Prevocational • Transitional Employment Support • Intensive Supported Employment • On-going Supported Employment • Peer Supports • Support Services • Family Support and Training • Non- Medical Transportation • Self Directed Services Pilot (pending CMS approval) Home and Community Based Services for HARP enrollees and HARP eligible HIV-SNP enrollees • Rehabilitation • Psychosocial Rehabilitation • Community Psychiatric Support and Treatment (CPST) • Habilitation • Respite • Short-Term Crisis Respite • Intensive Crisis Respite • Educational Support Services

18. Rest of State HCBS Designation Process The BH HCBS application is available on the OMH website and application are due 9/14/2015 Providers must complete an application to be identified as a “State designated BH HCBS provider” for each service they plan to deliver A provider attestation form is required, indicating that the provision of the service is consistent with the standards included in the HCBS provider manual OMH/OASAS will compile a list of all providers that have completed an application and attested to meeting the service standards In order to retain their “BH HCBS designation” providers must demonstrate on-going staff development competency for certain services

19. HARP Enrollment • All HARP eligible individuals identified by NYS will be offered an opportunity to enroll into a HARP • HARP eligible members will be passively enrolled in a HARP if they are enrolled in a Plan whose MCO offers a HARP product • These members will have the choice to opt out • Individuals initially identified as HARP eligible who are enrolled in an MCO without a HARP will not be passively enrolled • They will be notified of their HARP eligibility and referred to the NYS Enrollment Broker (New York Medicaid Choice) for education about enrollment options

20. HARP Choice Ability to opt-out of HARP or choose different Plan: • Individuals identified for passive enrollment will be notified by the NYS Enrollment Broker • They will be given no less than 30 days to opt out or to select another HARP • Once enrolled in a HARP, members are allowed 90 days to choose another HARP or return to Medicaid Managed Care • After 90 days, they are locked into the HARP for 9 additional months (after which they are free to change Plans at any time)

21. Provider Technical Assistance • NYS is funding the Managed Care Technical Assistance Center (www.mctac.org) to offer support and capacity building for providers. Subject areas include: • Contracting • Business & Clinical Operations Innovation • Home and Community Based Services • Evaluating, measuring, & communicating • Billing, Finance & Revenue Cycle • Utilization Management • Additional BH HCBS provider trainings • BH HCBS (with Center for Practice Innovation) • Business Practices (targeted at small providers)

22. Provider Start-Up Assistance • Funding available for up to two years • Priority given to BH HCBS providers and agencies with little or no Medicaid or Medicaid Managed Care experience • Key areas for Start-Up assistance include: • Health Information Technology (HIT) • NYS is developing a process to assist behavioral health providers who currently do not have the technological infrastructure to efficiently transition to a managed care system • HCBS provider Start-Up grants • Providers must demonstrate a contractual relationship (or letters of intent) with HARPs

23. Draft Rest of State Rates PM/PM by Region • Draft Rest of State HARP Rates can be found on the OMH website: http://omh.ny.gov/omhweb/bho/harp-ros-draft-rates.pdf

24. RFQ Questions and Answers

25. FAQ Review Process • NYS will review questions received to date and provide answers • Complete RFQ questions first followed by expedited RFQ questions • NYS verbal responses to additional questions received today must be considered preliminary answers • Final answers will be posted as soon as possible on the DOH, OMH, and OASAS websites

26. Complete RFQ: General Question: Would the State please share the Q&A prepared for the downstate RFQ? Response: FAQs from the NYC applicants conference can be found online at: http://www.omh.ny.gov/omhweb/bho/faq.pdf Note: Answers to some of these questions have changed. NYS is in the process of reviewing these FAQs and will update as appropriate in the near future.

27. Complete RFQ: General Question: Please confirm the State requires 4 complete hardcopies of the response. In addition, please clarify whether the electronic submission (PDF and Word) should include attachments or just the narrative response to Section A through K. Response: RFQ responses requires 4 complete responses and the PDF/Word versions should include attachments where possible.

28. Complete RFQ Section 1.5.A.ii Program Design Question: If the member refuses a Health Home, is the HARP allowed to provide case management? If so, how is that funded? Response: The HARP is responsible for care coordination, either though a Health Home or other State-designated entities. This service is included in the PMPM capitated rate. If a person refuses Health Home enrollment, the HARP must contract with a Health Home (or other state designated entity) to complete the assessment and develop the HCBS plan of care (POC).

29. Complete RFQ Section 1.5.A.ii Program Design Cont’d The Health Home must bill the HARP for delivery of these two services at the rates established by the State. Once the BH HCBS POC has been developed, the Health Home care manager forwards it to the HARP which is responsible for monitoring and implementing the POC. The HARP will not be paid an additional fee for monitoring and implementing POCs for their members who choose not to enroll in Health Homes.

30. Complete RFQ Section 1.5.A.ii.b Program Design Question: What are the metrics for BH HCBS and Health Home providers, or is it up to the HARPs and MCOs to determine the performance metrics per their contracts with those Health Homes and BH HCBS providers? Response: For BH HCBS, the Federal assurance and sub assurance requirements are being finalized. Additional information will be forthcoming.

31. Complete RFQ Section 1.7.C System Goals, Operating Principles, Requirements and Outcomes Question: Are there standard reporting requirements/monitoring mechanisms or processes Plans are expected to use? Also, are these general outcomes or specific to HARP members/MMC members who access BH services? Response: Plans will continue to be responsible for reporting requirements in QARR. NYS will issue additional guidance regarding required transitional monitoring reports specific to BH service utilization.

32. Complete RFQ Section 1.8.E.vi Covered Populations and Eligibility Criteria Question: Please clarify what entails a significant change in an individual’s circumstances or needs. Response: Significant change is when an individual experiences an acute episode, is re-hospitalized or experiences an event where additional support is required to live safely in the community.

33. Complete RFQ Section 1.10.E Covered Populations and Eligibility Criteria Question: What are the authorization requirements related to BH HCBS? Response: NYS is working in collaboration with the Health Plan Association to develop a uniformed UM policy for BH HCBS and plan of care.

34. Complete RFQ Section 3.1.I Organizational Capacity Question: Is the Plan required to comply with 8am-6pm hours of operation for core business operations if this varies from existing Plan hours? Response: Yes, Plans must comply with all standards reflected in the RFQ.

35. Complete RFQ Section 3.2.A.iv.b Experience Requirements Question: Please clarify the Plan’s responsibility to deliver cultural competency training directly to provider staff vs. establishing a monitoring mechanism Response: This RFQ requires Plans to monitor compliance with these training requirements, including cultural competence. Whenever possible, training and education for providers should be provided in coordination with the Regional Planning Consortiums (RPCs).

36. Complete RFQ Section 3.3.L.vi Contract Personnel Question: As a small HARP (under 4,000 members), an MCO would be allowed to share key staff across products (e.g., MMC and HARP). If an MCO with a small HARP delegates services to a BHO, can key BHO staff (e.g., CMO, Med Director) serve more than one Plan within the BHO’s book of business? Response: Yes, this is correct.

37. Complete RFQ: Section 3.9.E.ii Utilization Management Question: What are authorization requirements related to LOCADTR services? Response: LOCADTR is for initial and ongoing level of care determinations tool for all OASAS certified program types. LOCADTR is a patient placement criteria system designed to assure that a client in need of substance use disorder services is placed in the least restrictive, but most clinically appropriate level of care available that is to be used in making all initial and ongoing level of care decisions in New York State.   LOCADTR is developed and updated, as appropriate, by OASAS, and is the clinical level of care tool that assesses the intensity and need of services for an individual with a SUD.

38. Complete RFQ: Section 3.9.E.ii Utilization Management Cont’d The Contractor shall ensure that its’ Participating Providers and/or Contractor’s utilization management staff use the LOCADTR 3 assessment tool to make initial and ongoing level of care determinations for SUD services. Please note that while OASAS encourages Plans to identify individual or program service patterns that fall outside of expected clinical practice OASAS does not permit Plans to request / require from providers regular treatment plan updates for otherwise routine outpatient and opioid service utilization.

39. Complete RFQ Section 3.10.G.i Clinical Management Question: What is the State’s expectation as it relates to the Plan developing definitive strategies to promote BH/medical integration that include co-location of BH practitioners in primary care and primary care into BH locations? Performing Provider Systems (PPS) will lead efforts in this area, bolstered by the commitment of DSRIP funding and the State’s support for regulatory relief. Short of lending guidance/input and support for the PPSs, it’s not clear what the State’s assumption is for a Plan role in this integration.

40. Complete RFQ Section 3.10.G.i Clinical Management Response: Plans should describe new processes and procedures they can implement that promote BH/Medical integration given the multiple statewide initiatives and resources available in Health Homes, DRSIP, etc.

41. Complete RFQSection 4.0.A.5 Organization, Experience, and Performance Question: Does the page limit apply to each government/public sector customer that the Plan/delegate has (i.e., one page per customer), or will the Plan/delegate need to list all of its government/public sector customers on one page. Response: Plans/delegate must submit 1 page per each government/public sector customer.

42. Complete RFQ Section 4.0.A.5 Organization, Experience and Performance Question: Please clarify that this question is only for a BHO responding on behalf of a health plan. We otherwise assume that a Plan’s own experience in managing the BH population and benefits will be answered in A.4. Response: If the Plan is contracting with a BHO to meet the experience requirements both the Plan and the relevant delegate must respond to questions A.4 and A.5.

43. Complete RFQ Section 4.0A.7 Organization, Experience and Performance Question: Please clarify whether this question applies only to BHO applicants or whether Plans proposing to manage without BHO assistance should nonetheless provide details about their current key staff. Response: The RFQ allows the Plan to meet experience requirements by either contracting with a BHO or using experience of key and managerial BH staff. This question pertains to Plans using experience of key and managerial staff.

44. Complete RFQ Section 4.0A.12: Organization, Experience and Performance Question: Please clarify whether this question applies only to a BHO. If it applies to an MCO applying without BHO assistance, has DOH provided the current rate components that comprise the BH portions of a Plan’s rate? It’s not currently clear in a Plan’s rate sheets what proportion of its revenue is for the BH service continuum. Response: This question applies to the MCOs and HARPs. This question only applies to the amount the Plan paid in calendar years 2013 and 2014.

45. Complete RFQ Section 4.0.B.4 Personnel Question: Please clarify whether it is acceptable to include total FTE counts in some service areas of a Plan if all FTEs in the service area will be trained and otherwise be available for carve-in or HARP services. Response: Any staff working on the product line must be trained and reflected in the HARP and MMC Personnel Requirements Table. This table must identify the percentage of time that the staff will work on the MMC and the HARP.

46. Complete RFQ Section 4.0.B.9 Personnel Question: Are completed training materials required to be submitted with the RFQ response, or will the training plan be sufficient? Some materials are still in process and will not be completed until DOH releases further guidance to upstate Plans. Response: A training plan is sufficient as long as it addresses the criteria in Question B.9. Specific training materials will be reviewed during the Readiness Review process.

47. Complete RFQ Section 4.0.C.1 Member Services Question: Is it acceptable to maintain two member services call functions – a Plan’s general member services line (with increased training on carve-in and HARP services) and a BH service line for assistance in accessing care, speaking to a care manager, seeking urgent assistance? The BH line would not be used to handle typical member issues, such as requesting a replacement ID card, a replacement copy of a handbook, etc. The process for hand-offs to the BH line would be described in order to show how the two centers work together.

48. Complete RFQ Section 4.0.C.1 Member Services Response: It is acceptable to maintain two member services call functions, as long as the BH services call center staff are knowledgeable about: i. Covered services; ii. NYS managed care rules; iii. Approved BH UM criteria; iv. Approved BH HCBS rules and requirements (for HARPs); and v. Provider networks. The Plan must describe how the two lines work together and how physical and behavioral health data will be integrated and available to both behavioral health and general member services personnel.

49. Complete RFQ Section 4.0.D.1 Network Management Describe the specific service area [county or counties] in the responder’s current Medicaid Managed Care contract with NYS including anticipated enrollment and utilization, and the cultural, linguistic and other demographic information that will influence network development. Question: Can you please provide guidance on the best approach for responding to this question?

50. Complete RFQ Section 4.0.D.1 Network Management Response: The State recommends outlining the response as follows: