Division of Medical Assistance: Integrated Care Workgroup Courtney Cantrell, PhD

1. Division of Medical Assistance: Integrated Care Workgroup Courtney Cantrell, PhD Assistant Director for Behavioral Health Division of Medical Assistance (DMA)

2. Division of Medical Assistance • The mission of the Division of Medical Assistance (DMA) is to provide access to high quality, medically necessary health care for eligible North Carolina residents through cost-effective purchasing of health care services and products.

3. Medicaid & NCHC Programs • Medicaid is a health insurance program for low-income individuals and families who cannot afford health care costs. Medicaid serves low-income parents, children, seniors, and people with disabilities. ***Stay enrolled!! • N.C. Health Choice for Children (NCHC) is a free or reduced price comprehensive health care program for children. • ***NC Tracks!! http://www.ncmmis.ncdhhs.gov

4. Medicaid Policy • Subject to Federal Laws and Social Security Act, as well as state statutes; often follows Medicare • State plan submitted to Centers for Medicare and Medicaid Service (CMS) for approval (unmanaged visits, services covered, providers who can provide services, etc) • WAIVERS – allow us more flexibility to do things that would not be approved in a regular state plan

5. Medicaid Waivers • Waive provisions of Social Security Act (SSA) • Each waiver number refers to a section of SSA • Each waives provisions of Section 1902 (requirements for State Plans)

6. NC Medicaid Waiver for MH/SA/IDD Services • Medicaid Program follows Title XIX of the SSA • Medicaid Managed Care Program under CFR 438 • DMA gets a 1915b/c waiver from CMS (Centers for Medicare & Medicaid) • (b) waiver allows DMA to contract with a managed care vendor (LME) for oversight of mh/sa/dd services in their counties. • PIHP: Prepaid Inpatient Health Plan • (c) Waiver allows DMA to offer HCBS (habilitation) • DMA monitors the company (LME-MCO) to make sure that they follow all Medicaid rules. • CMS monitors DMA (follow SSA)

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8. Covered Benefit Package • All services found in the 8x series of DMA Clinical Coverage Policies - -regular outpatient and enhanced services*** • LME-MCO cannot be more restrictive than DMA Clinical Coverage Policy • Audits should be based at least on DMA policy

9. Covered Benefit Package • Inpatient Behavioral Health Services (DMA Clinical Coverage Policy 8B) • Inpatient services for the treatment of mental health and substance abuse disorders and developmental disabilities • Hospital Emergency Department (ED) services: Each LME-MCO is responsible for all facility, professional, and ancillary charges for services delivered in the emergency department to individuals with a discharge diagnosis ranging from 290 to 319.

10. Covered Benefit Package • Outpatient Behavioral Health Services including all services provided by psychiatrists for recipients with a diagnosis in the 290-319 range (DMA Clinical Coverage Policy 8C) • Excluded: E&M codes by physicians (except psychiatrists) –even if dx is 290-319 • NOTE: Co-located BH providers will need to enroll with the LME-MCO

11. Covered Benefit Package • Psychiatric Residential Treatment Facilities (PRTFs) (DMA Clinical Coverage Policy 8D1) • Therapeutic Foster Care (TFC) (DMA Clinical Coverage Policy 8D2) • Residential Child Care Levels II group, III, IV (DMA Clinical Coverage Policy 8D2)

12. Excluded Services/Populations • Early Intervention Services (0-2) are currently excluded • CDSA, including case management • CBRS • Outpatient MH services • Very small #s of claims • FQHCs are excluded • Any BH service for children 3-5 are included • INPT, OTPT, Enhanced, residential

13. DMA Reporting- B Waiver • Use of Services • Mental Health Utilization – Inpatient Discharges and Average Length of Stay* • Mental Health Utilization – Percentage of Members Receiving Inpatient, Intermediate Care, Ambulatory and Other Support Services* • Chemical Dependency Utilization – Inpatient Discharges and Average Length of Stay* • Chemical Dependency Utilization - Percentage of Members Receiving Inpatient, Intermediate Care, Ambulatory and Other Support Services • Integrated Care

14. Where is Integrated Care? • 96150 and 96151 are billed by physicians directly to DMA (provided incident-to by the BH provider) • All therapy codes (covered under 8x policies) are billed to the LME-MCO • Contractual expectation that LME-MCOs support Integrated Care by reporting Integrated Care efforts annually • Adjustments made to Clinical Coverage Policy 8C (no CCA for brief interventions in primary care clinic) • Working through Provider Services to help with enrollment of BH agencies as CCNC medical homes ***Be careful to still heed the rules – if you are a BH provider (LCSW, Psychiatrist, etc) you can only direct-bill the LME-MCO; non-physician BH provideres cannot be enrolled as a physician group.)

15. The Future: Partnership for a Healthy North Carolina • Built based on over 160 responses to RFI • Improve behavioral and physical health care outcomes • Build on gains and innovations in community-based care and take it to the next level • *Look at each person as a whole, treating behavioral and physical health needs in a collaborative way to improve the health of each individual. http://www.ncdhhs.gov/medicaidreform/

16. The Future: Partnership for a Healthy North Carolina • Person-Centered –single entry point into system • Recipient CHOICE of 3-ish statewide Comprehensive Care Entities that treats the whole person • CCE provides functional needs assessment at single entry point • Comprehensive care focused on outcomes (backed by strong contract) • Customer Service: simplified for providers and patient-centered

17. OnGoing Efforts Get Involved! Get to know what can be billed and when; read and understand policy (we can help); know your value ($) Give us Feedback! Systems are complex; let us know if something isn’t working or if you find something that could be improved Periodically policies go up for public review—feedback is carefully considered http://www.ncdhhs.gov/dma/mpproposed/

18. Medicaid/DMA Contacts Courtney Cantrell, PhD Assistant Director for Behavioral Health 919-855-4385 Courtney.M.Cantrell@dhhs.nc.gov http://www.ncdhhs.gov/dma/services/behavhealth.htm http://www.ncdhhs.gov/dma/lme/MHWaiver.htm