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Behavioral Heath Solutions for Medical Health Plans

Behavioral Heath Solutions for Medical Health Plans. Mary Ruiz, President/CEO, Manatee Glens 2014 Guide to Behavioral Health Conference Orlando Florida. Florida’s Medicaid Managed Medical Assistance. Florida’s General Plans Managed Medical Assistance. Amerigroup (Wellpoint)

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Behavioral Heath Solutions for Medical Health Plans

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  1. Behavioral Heath Solutionsfor Medical Health Plans Mary Ruiz, President/CEO, Manatee Glens 2014 Guide to Behavioral Health Conference Orlando Florida

  2. Florida’s MedicaidManaged Medical Assistance

  3. Florida’s General PlansManaged Medical Assistance • Amerigroup (Wellpoint) • Better Health (PSN) • Coventry (Aetna) • First Coast Advantage • (PSN Shands) • Humana • Integral (PSN FQHC) • Molina

  4. Florida’s General PlansManaged Medical Assistance • Preferred Medical (HMO) • Prestige (Blue Cross) • SFCCN (PSN) • Simply (HMO) • Sunshine (Centene) • United Health • Staywell (Wellcare)

  5. Florida’s Specialty PlansManaged Medical Assistance Clear Health Alliance HIV/AIDS (Simply) Freedom Health Duals Chronic (HMO) Magellan Complete SPMI Positive Healthcare Florida HIV/AIDS Sunshine Health Plan Child Welfare (Centene) Children’s Medical Services Chronic (FL Department of Health)

  6. Florida’s MedicaidManaged Medical Assistance

  7. Florida’s MedicaidManaged Medical Assistance • Community Mental Health Handbook Benefits • Targeted Case Management Handbook Benefits • Fee for Service Formulary for One Year • No PCP Referral for BH Services—direct access required Behavioral Health Benefits

  8. Florida’s MedicaidManaged Medical Assistance • Substance Abuse • Child Welfare Overlay • Comp Assessment • Transportation • Therapeutic Foster Care • Statewide Inpatient Psychiatric • Therapeutic Group Fee for Service To Managed Care

  9. Florida’s MedicaidManaged Medical Assistance Access Standards No Wait List Urgent One Day Sick Care One Week Well Care One Month

  10. MMA Behavioral Health Coordination Contract Requirements • State hospital 6 months of last 36 months • 2 admissions to state hospital in 36 months • 3 admissions to crisis, SRT or inpatient psych in 12 months • Comorbid polypharmacy • Exceed prescription limits

  11. MMA Behavioral Health Contract Requirements • County 24/7 emergency service with RN and on call behavioral health specialist • ALF community living support plan and access to Drop In Centers • Outreach and care management for non TCM clients (homeless, ALF, state hospital, jails, juvenile justice) • Participation in DCF Planning Processes SIPP, State Hospital

  12. Medicaid Health Plans of America • Transition Coaches & Peer Bridgers (Optum) • Peer Led Warm Line (Centene) • Pediatric Residential Treatment Diversion (Optum Tennessee) • Health Risk Assessment SMI (Centene) Best Practices Compendium Serious Mental Illness

  13. Provider Challenges • Lower Rates • Increased Utilization Management • Staff Attrition to Plans • Increased Admin Costs • Decreased Cash Flow • Lower Collection Rates • Inclusion in Networks

  14. System Challenges • End of Medical Loss Ratio for Behavioral Health • Increased Spend on Medical Over Behavioral Health • Increased Spend on BH Pharmacy over BH Hospital • Disincentive for Risk Share • Loss of Transparency on Total Behavioral Spend and Practices • Workforce

  15. New Possibilities? • Pay for Performance • Primary Care Coordination • Telemedicine • Substitute Services • Healthy Behaviors • Mental Health Excellence Act

  16. Pay for Performance System Provider What is the real total cost of care? Does the data bear up? What innovations are needed to move outcomes? • Does it improve outcomes? • How can outcomes differ if plan is the same? • What are the right payment models?

  17. Florida MMA Contracted Quality Measures

  18. Florida MMA Contracted Quality Measures

  19. Florida MMA Contracted Quality Measures

  20. Florida MMA Contracted Quality Measures

  21. Pay for Performance MMA Contract Penalties • $10,000 below 50% per performance group • Liquidated damages $1.25-$3.50 per member • Failure for face to face with case manager/bh provider $5,000 each occurrence

  22. Pay for PerformancePayment Models Payment Model Precedence Mental Health Excellence HMO Primary Care Florida BNET Prepaid Mental Health Plans Enhanced Rate Monthly Cap Rate for Care Management Monthly Bundled Payment for Treatment Capitation

  23. Pay for PerformancePayment Models Payment Model Performance Targets Access to Care Adherence or High Risk High Cost Medical Home Enhanced Rate Monthly Cap Rate for Care Management Monthly Bundled Payment for Treatment Capitation

  24. Primary Care Coordination PCP Concerns • Mandatory assignment of a PCP required • 67% of PCP’s say they have no behavioral health referral • 30-50% of patients refuse behavioral health referral • Psychiatrists don’t interrupt sessions to take physician calls

  25. Primary Care Coordination PCP Adherence Rates 20% of patients don’t fill PCP scripts 50% adherence blood pressure medications 20% inhalant compliance pediatric asthma 56% diabetic adherence in the year following diagnosis

  26. Primary Care Coordination PCP Outreach Build Primary Care Data Base Direct Sales Marketing Referral Concierge Lunch and Learns Tours CME/Medical Society Talks Troubleshoot Referral Relationship

  27. Primary Care Coordination Plan Demonstration Projects • Adherence for asthma, diabetes, cardiac patients • Comorbid polypharmacy • Substance abuse • All cause readmissions • High cost • Medical home features to PCP practice • Health risk assessments for BH caseload

  28. Primary Care Coordination Plan Demonstration Projects • Body Mass Index • Immunization Status • HbA1c Levels • Blood Pressure • Risk Identification • Functional Outcomes • Medication Compliance

  29. Telemedicine 1. Community Mental Health Handbook 2. MMA Contracts 3. Provider Contracts • Allowed for behavioral health, dental and physician services • Hub and spoke • Telemedicine modifier code for sixteen services • Optional not required • Medicaid prohibition to pay for equipment

  30. Best Bets for Telemedicine Enhanced Rate High Volume Collaborative Host • Federally Qualified Health Center • Emergency Room • Department of Health • Residential Treatment Center • Rural Locations • Children Psychiatry

  31. Florida’s Substitute Services • Carry forward of the Prepaid Mental Health Plans • Not designed for substance abuse prevention or treatment services • Adds medical home dimensions to care • Permitted but no plan has requested use

  32. Substitute Services • Plan Request • AHCA Approval • Provider Contract • H0038 Peer Services • H2015 Outreach • H006HE Respite • H2019HB In Home • 0912 Partial Hospital • T1027 Family Training • H0046HK Therapeutic In Home • H2022 Wrap Around

  33. A Florida Strategy forSubstitute Services • Turn on Substitute Service Codes • Redefine to clarify applications to substance abuse especially partial hospital, peer and outreach • Add SBIRT at higher rate • Allow innovations and flexibility with new definitions or codes

  34. Healthy Behaviors Alcohol and Drug Screening and Treatment • Annual Provider Training • PCP screening on first visit, routine physicals, ER utilization patterns • Provide alcohol or substance abuse recovery program • Plan reports on activities to Florida Medicaid • Residential Detox not a federally covered service

  35. Healthy Behaviors • Incentive Plans up to $50 Per Enrollee • Smoking Cessation • Medically directed weight loss • Alcohol or substance abuse identification • Identification of Pregnant Women Health Behavior Services

  36. Healthy Behaviors • Manage incentive plan • Sell smoking cessation or weight loss for current clients • Propose alcohol or substance abuse screening and engagement service for PCP • Outreach to pregnant women to engage in prenatal care Plan Demonstration Projects

  37. MMA ADVOVACY INITIATIVES • Behavioral Health Medical Loss Ratio • Code Innovations for Behavioral Health • Transparent data, bids, contracts, reports and provider manuals • Mental Health Excellence Act • Require that plans include CMHCs in network

  38. Mental Health Excellence Act • National Council for Behavioral Health Initiative • Act of Congress on March 31, 2014 • Improves Medicaid rate reimbursement 90% FMAP • Creates certified community behavioral health clinics

  39. Mental Health Excellence Act • Provides $25m in state planning grants for 2 year pilot • Eight states selected to participate for 2 year pilot • Requires states to develop prospective payment system

  40. Mental Health Excellence Act • Publication of clinic criteria Sept. 1, 2015 • Award of planning grants Jan. 1, 2016 • Selection of participating states Sept. 1, 2017

  41. Mental Health Excellence Act Clinic Certification Requirements • Staffing • Access • Care Coordination • Scope of Services • Quality • Nonprofit/Government

  42. Mental Health Excellence Act

  43. How Florida GetsMental Health Excellence • Florida providers prepare to meet Excellence Act certification • Florida legislature authorizes AHCA to apply for planning grant • Associations assist AHCA in developing planning grant application • Advocate for Florida at Federal Level • Better align MMA with Excellence Act • Florida secures planning grant

  44. Don’t Miss This! Thursday, August 7th - 1:30pm-3:00pm workshop Excellence in Mental Health Act: Where Do We Go From Here? Grand Cypress C Rebecca Farley National Council for Behavioral Healthcare

  45. The Finish Line

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