NJPRA annual conference “A view from the Division of Mental Health & Addiction Services”

1. NJPRA annual conference“A view from the Division of Mental Health & Addiction Services” Lynn A. Kovich Assistant Commissioner October 26, 2012

2. Waiver • Rate Setting Update • CSS Regulations • Outpatient Provider Survey • Reinvestment of Savings from HPH Closure • RFP updates Agenda

3. Comprehensive Waiver approved 10/1/2012

4. Model for reform and innovation Streamlines program administration and operation Preserves eligibility and enrollment Does not include ER co-pay Enhances and coordinates services to specialty populations Rewards efficiency in care The full waiver application and final terms and conditions can be found online at: www.state.nj.us/humanservices/dmahs/home/waiver.html Waiver Highlights

5. Currently, BH care under Medicaid FFS is fragmented with an over-reliance on institutional, rather than community-based care Consumers receive care through managed care organizations (MCOs) with limited or no formal protocols for coordination between medical and behavioral health delivery systems Approximately two-thirds of Medicaid’s highest cost adult beneficiaries have MI and one-fifth have both MI and a substance use disorder Need for Care Integration

6. Integrates behavioral health and primary care Develops innovative delivery systems – MBHO, ASO Supports community alternatives to institutional placement Braids funding Provides opportunities for rate rebalancing No-risk model transitions to risk-based model Increased focus on SAI and consumers with developmental disabilities What Does Medicaid Waiver Mean for Behavioral Health Services?

7. Roles and Responsibilities in a Managed Behavioral Health System • Managed behavioral health systems are typically organized around the following processes or core functions • The state, providers, members, and the MBHO each have specific roles and responsibilities within these processes • These may vary based on what the state opts to delegate to the MBHO and what it retains • Some processes may not be delegated to the MBHO; (ie, verification of Medicaid eligibility)

8. Roles and Responsibilities in a Managed Behavioral Health System Eligibility Network Development and Management Assessment and Referral Utilization Review Claims Administration Data Analytics Care Management Quality Management Financial Management

9. Non-entitlement services remain non-risk • Advantages of going risk • Greater budget predictability • Greater flexibility • Rates • Services • Reinvestment • Aligned incentives Aspects of the Risk Model

10. Federally mandated consumer protections in a risk model • grievance procedures • fraud and abuse • civil and monetary penalties • enrollee rights and must be informed and re-informed of rights • quality assurance programs • mandatory external Quality review • prohibition against provider incentive to decrease care or tie compensation to utilization decisions • Other protections could include: • consumer bill of rights • Post-stabilization requirements Safeguards of the Risk Model

11. State establishes policy and standards for: • MBHO mission/vision to serve BH consumers • MBHO performance • Provider network participation and performance • Consumer outcome indicators and related process measures • Allows for consumer and family participation in the design of access and quality standards and ongoing monitoring of performance and outcome • Per the ‘medical loss ratio’ provision, MBHO must spend majority of resources on care • Sets minimum amount on services • Limits maximum administrative spending • Limits maximum profit to be earned • Reinvestment in new capacity Safeguards of the Risk Model cont’d

12. Stakeholder Involvement • DMHAS, in partnership with NJ Medicaid, have developed a stakeholder input process to: • Inform the DHS’ values and vision regarding the design and implementation ASO/MBHO • Elicit broad stakeholder input regarding the design and development of the various components of the ASO/ MBHO • Initiate a targeted workgroup process to inform more detailed level components of the ASO/MBHO • Identify and leveraging opportunities under Health Care Reform to support a transformed system • The final Steering Committee report and recommendations were posted in June 2012 at http://www.state.nj.us/humanservices/dmhs/home/mbho/Stakeholder_final_report_june15_2012.pdf

13. The Stakeholder Steering Committee identified guiding principles to inform the design and implementation of the ASO/MBHO: • The ASO/MBHO must be person-centered, reflecting the strengths, resources, challenges, and needs of consumers. • The system needs to be easy for consumers and families to access and use. It is critical to ensure that the ASO/MBHO itself does not create additional barriers for consumers seeking to access services. • The State should pursue reimbursement rates at levels that will induce a sufficient number of providers to enter the marketplace to deliver necessary services to consumers, while meeting availability, access, geography and quality objectives and regulatory requirements. • Financial and non-financial incentives need to be established to build a system that supports the over-arching principles of wellness and recovery, while tracking monitoring utilization and costs across the continuum of care to ensure that resources are expended efficiently and desired outcomes are achieved. Guiding Principles

14. The ASO/MBHO design should be informed by the fundamental belief that with services and supports consumers can manage their behavioral health conditions while regaining and sustaining purposeful and meaningful lives. • This should be reflected in the system design by emphasizing the integration of primary and behavioral healthcare services managed by the ASO/MBHO and the Medicaid managed care organizations (MCOs) to promote holistic, community-based care for the purpose of overall consumer wellness and recovery. • The transformation of the behavioral health system of care from an unmanaged, cost-related contracting system to a managed system that purchases services on a fixed-rate, fee-for-service basis is a challenging step towards creating an environment where consumers receive appropriate care and supports in a manner that is efficient, accountable, and affordable to the taxpayers. Guiding Principles

15. While the implementation of the ASO/MBHO is anticipated to achieve improved behavioral health quality and outcomes, and contain costs, government, community, and constituent stakeholders should be cognizant that many desirable outcomes will not be fully realized without a commitment to collaboration and accountability shared by other systems that also engage and serve behavioral health consumers including other programs and services administered by DHS, the Departments of Health and Labor and Workforce Development, as well as the judiciary and criminal justice systems. Guiding Principles

16. Current treatment and recovery services funded by DMHAS will remain funded, but will fall under the ASO/MBHO Cost reimbursement contract methodology does not closely tie reimbursement to service utilization and does not incentivize cost effectiveness at the agency level The managed care arrangement would transform all community cost reimbursement treatment contracts to a fee-for-service (FFS) reimbursement method Prevention services would remain cost reimbursement at the onset of the ASO/MBHO ASO Impact on Services & Contracts

17. Timeline

18. Rate setting UPDATE

19. CSS Regulations

20. CMS approved state plan amendment to provide CSS in 2011. CSS is a mental health rehabilitation support service.  It assists individuals diagnosed with a mental illness to attain the skills necessary to achieve and maintain their valued life roles in employment, education, housing and social environments. Billing rates are banded based on credentials of staff person delivering the service.  The SPA includes a rate for individuals with lived experience diagnosed with a mental illness, to promote utilization of peers in the delivery of CSS. Regulations are due to be published early calendar year 2013 and promulgated the summer of 2013. Only licensed providers can bill CSS CSS will be provided and billed by supportive housing providers Community Support Services Regulations

21. Outpatient provider survey

22. The reinvestment of some HPH savings, $2.5M annualized, will enable the expansion of outpatient services The DMHAS sent a survey out to contract providers requesting information regarding the individuals served, staffing and waits for service to assist in the assessment of outpatient needs across the state Responses must be submitted by November 9, 2012 The DMHAS will also look at other indicators to identify need Counties where outpatient expansion will take place will be based on those counties demonstrating the greatest need RFP to be issued and proposals awarded in FY 2013 Outpatient Provider Survey

23. Reinvestment of HPH Savings from Closure

24. Enabled the following expansions • Creation of 100 new subsidies, operated by DMHAS for (KFT, county hospitals, non-CEPP state hospitals, RHCF/Boarding home, individuals in existing contract housing (i.e., group homes), individuals who frequent the acute care system, are homeless or in substandard housing. • Career Services (supported employment / supported education) • Outpatient Services • Diversion programs for individuals who are high utilizers of emergency department and psychiatric emergency services • Behavioral Health Homes • Supportive Housing for individuals in state hospitals (133 beds) Reinvestment of HPH Savings from Closure

25. Requests for Proposals

26. Final awards were issued on 10/12/12 to MHA Monmouth County (Monmouth County) and St. Joseph’s Hospital/Medical Center (Passaic County) for Projects of Assistance in Transition from Homelessness (PATH) in Monmouth and Passaic Counties. Up to $202,585 annually will be available to support the Monmouth County program and up to $367,397 will be available to support the Passaic County program awarded under this RFP. Final awards of grant funding were issued to the Mental Health Association of Morris County (Morris) and Bridgeway Rehabilitation Services, Inc. (Sussex) on 10/12/12 for the integration of peer specialists into DMHAS funded Integrated Case Management Service Teams (ICMS). This initiative will be implemented through a best practice approach to the delivery of consumer-operated services. There are a statewide total of 2 positions being implemented for this initiative. A final award was issued to Hampton Behavioral Health Center on 10/22/12 to fund up to $3 million on an annualized basis to provide access to a minimum of 19 involuntary (closed acute) adult inpatient treatment beds which can serve as a direct alternative to admission to a State Hospital. Admission to the solicited beds will come via transfers from specified STCF. Admissions will be prioritized to consumers who would otherwise be admitted to Ancora Hospital from Burlington County. DMHAS issued an RFP on 8/1/12 for the development of one Involuntary Outpatient Commitment (IOC) program. This will be the sixth IOC program funded by DMHAS. IOC programs are currently funded in Burlington, Essex, Hudson, Union and Warren Counties. No proposals will be considered from applicants proposing to provide IOC in one of the five counties where IOC already exists. Proposals were due on 9/5/12, and preliminary awards were made on 10/19/12. $293,766 is available annually for this initiative. RFPs Recently Awarded

27. DMHAS issued an RFP on August 20 for the creation of new supportive housing opportunities for mental health consumers who are at imminent risk of hospitalization and homelessness for a total annualized amount of $2,363,121. Proposals were due 9/26/12 and preliminary awards will be made no later than 10/31/12. • DMHAS issued an RFP on August 30 for the development of 30 supportive housing beds from existing DMHAS contracted PACT and RIST programs to provide community support for persons on CEPP status discharged from state psychiatric hospitals for an annualized amount of $1,050,000.  Proposals were due 9/27/12 and preliminary awards will be made on 11/5/12. • New Jersey was awarded $7.5 million from SAMHSA to implement a five year screening, brief intervention and referral to treatment initiative. DMHAS has made available up to $5,231,665 for up to 5 years for this initiative. Approximately $1,047,720 will be available during the first year of implementation. Proposals were due on 10/19/12, and the preliminary award will be made no later than 11/2/12. RFPs Being Reviewed

28. On 10/3/12 DMHAS issued an RFP that will permit the development of Early Intervention Support Service (EISS) programs that will provide rapid access to short term, recovery-oriented crisis intervention and crisis stabilization services for persons with a serious mental illness. DMHAS is seeking to competitively award programs in Bergen, Cumberland and Mercer Counties and anticipates three separate awards of up to $1,000,000 each. Applications must be received by 11/9/12, with applicants being notified no later than 12/20/12. RFP’s Currently Posted

29. Two Supportive Housing RFPs to develop 248 beds Three Psychiatric Emergency Screening Centers (counties TBD) Career Services (supported employment and supported education) Outpatient Services RFPs Not Yet Posted