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Drug Medi-Cal Organized Delivery System Pilot Program DHCS Stakeholder Webinar October 22, 2015 1
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Drug Medi-Cal Organized Delivery System Pilot Program
DHCS Stakeholder WebinarOctober 22, 2015
1
Overview of Presentation Impact of Substance Use Federal Landscape Goals and Objectives of the Pilot Stakeholder Process Waiver Authority Critical Elements Standard Terms and Conditions Evaluation Regional Implementation
October 22, 20152
Presenters Karen Baylor, PhD, Deputy Director, MHSUD,
DHCS Marlies Perez, Division Chief, MHSUD, DHCS Don Kingdon, PhD, Harbage Consulting Molly Brassil, Harbage Consulting
October 22, 20153
Impact of Substance Use Substance use disorders (SUDs) occur when the recurrent use of alcohol
and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home
About 21.5 million Americans ages 12 and older (8.1%) are classified with a SUD (SAMHSA, 2014)
Untreated SUDs are associated with increased risks for a variety of costly chronic physical and mental healthcare conditions, avoidable hospitalizations, incarceration, and premature death
Addressing the impact of substance use alone is estimated to cost Americans more than $600 billion each year (SAMHSA, 2014)
Since 1999, opiate overdose deaths have increased 265% among men and 400% among women (SAMHSA, 2015)
October 22, 20154
Federal Landscape States have a tremendous opportunity to improve access to care for
individuals with SUDs, particularly in light of the coverage and benefit expansions under the Affordable Care Act (ACA).
Mental health and SUD services are notably included as one of ten essential health benefits that must be covered under Medicaid alternative benefit plans and Health Insurance Marketplace qualified health plans, with parity to covered medical and surgical services.
Although millions of adults across the country now, many for the first time, have health insurance that covers SUD services, most state delivery systems and benefit structures for treatment have historically been inadequate for the Medicaid population.
To date, most state Medicaid programs have only covered a minimal number of services, have insufficient provider networks, and few standards for this type of care.
October 22, 20155
Federal Landscape The Centers for Medicare & Medicaid Services (CMS) issued
guidance in July 2015 outlining the opportunities for states to design service delivery systems for Medicaid beneficiaries with substance use disorders.
Includes a new section 1115 waiver opportunity to build a robust continuum of care for beneficiaries with substance use disorders.
Strategies can also include short-term institutional services, such as short-term inpatient and short-term residential SUD services for individuals in institutions for mental disease (IMD).
California is the first 1115 project approved under this guidance.
October 22, 20156
California’s Goals and Objectives To test a new paradigm for the organized delivery of health care
services for Medi-Cal enrollees with a substance use disorder Will demonstrate how organized SUD care improves outcomes for
DMC beneficiaries while decreasing other system health care costs Promote both systemic and practice reforms to develop a
continuum of care that effectively treats the multiple dimensions of substance use disorders
Design a SUD benefit that guarantees a full continuum of evidence-based practices to address the immediate and long-term physical, mental, and care needs of the beneficiary
October 22, 20157
Stakeholder Process DHCS held nine Waiver Advisory Group meetings in 2014 and
2015 to inform the development of the pilot proposal to CMS Participants have included counties, provider representatives,
Alcohol and Other Drug counselor certifying organizations, Medi-Cal managed care plans, public interest advocates, the Legislature, and others
Meeting notes / materials posted on the website: http://www.dhcs.ca.gov/provgovpart/Pages/MH-SUD-PreviousMeetings.aspx
October 22, 20158
Critical Elements of Pilot Program Critical Elements of the DMC-ODS Pilot Program include:
Continuum of care modeled after ASAM Increased local control and accountability Greater administrative oversight Utilization tools to improve care and manage resources Evidence-based practices Coordination with other systems of care Special considerations for the criminal-justice involved
population
October 22, 20159
Waiver Authority The DMC-ODS Pilot Program is authorized and financed under
the authority of the state’s 1115 Bridge to Reform Waiver. The purpose of 1115 waivers is to demonstrate and evaluate
policy approaches that improve care, increase efficiency, and reduce costs.
Demonstrations must be “budget neutral,” which means that during the course of the project federal Medicaid expenditures will not be more than fed spending without the waiver.
The DMC-ODS Pilot Program will be elective for 5 years.
October 22, 201510
Standard Terms and Conditions Eligibility Benefits County Responsibilities State Oversight, Monitoring & Reporting Fiscal Framework
October 22, 201511
Eligibility No age restrictions Adults:
Enrolled in Medi-Cal Reside in Participating County Meet Medical Necessity Criteria:
One DSM Diagnosis for substance-related and addictive disorders (with the exception of tobacco)
Meet ASAM criteria definition of medical necessity for services based on ASAM criteria
October 22, 201512
Eligibility Youth:
Enrolled in Medi-Cal Reside in Participating County Meet Medical Necessity Criteria:
Be assessed to be at risk for developing a substance use disorder
Meet the ASAM adolescent treatment criteria (if applicable)
October 22, 201513
Benefits The continuum of care for SUD services is modeled
after levels identified in the ASAM criteria Counties are responsible for most levels; however, a
few of them are overseen / funded by other sources Counties may implement a regional model with other
counties Counties may contract with providers in other counties
in order to provide the required services
October 22, 201514
Benefits – Standard vs. Pilot Standard DMC services approved through the state plan benefit will
be available to all beneficiaries in all counties. Beneficiaries that reside in a Pilot county receive DMC-ODS benefits
in addition to other state plan services. County eligibility is based on the MEDs file. In counties that do not opt in, beneficiaries receive only those drug
and substance use disorder treatment services outlined in the approved state plan (including EPSDT).
Beneficiaries receiving services in non-opt in counties will not have access to the services outlined in the DMC-ODS.
October 22, 201515
Standard Benefits Existing Statewide Medi-Cal SUD Treatment Services Include:
Outpatient Drug Free Treatment Intensive Outpatient Treatment Naltrexone Treatment (with TAR) Narcotic Treatment Program Perinatal Residential SUD Services (limited by IMD exclusion) Detoxification in a Hospital (with TAR)
These benefits will remain available to all Medi-Cal beneficiaries, including those in non-pilot counties
October 22, 201516
Pilot Benefits DMC-ODS Pilot Counties are required to provide:
Early Intervention (coordination with FFS / MCPs) Outpatient Services (includes IOT and naltrexone) Residential (not limited to perinatal or restricted by IMD exclusion) Narcotic Treatment Program Withdrawal Management (at least one level) Recovery Services Case Management Physician Consultation
The following levels of service are optional for pilot counties: Partial Hospitalization (optional) Additional Medication Assisted Treatment (optional)
October 22, 201517
New Benefits Recovery Services
Focus on building beneficiary’s self-management skills and linking to community resources.
May be accessed after completing course of treatment (if triggered, relapsed, or to prevent relapse)
Case Management To assist a beneficiary to access necessary medical, educational, social,
prevocational, vocational, rehabilitative, or other community services. Physician Consultation
DMC physicians consulting with addiction medicine physicians, addiction psychiatrists, or clinical pharmacists to offer support with complex cases (i.e. medication selection, dosing, side effect management, adherence, drug-drug interactions, or level of care considerations)
October 22, 201518
Residential Services Non-institutional, 24-hour, non-medical, short-term residential
program that provides rehabilitative services Often requires treatment that is primarily slower-paced, more
concrete and repetitive in nature, with structured patterns of activities intended to restore cognitive functioning and build behavioral patterns within a community.
Each beneficiary lives on the premises and shall be supported in their efforts to restore, maintain, and apply interpersonal and independent living skills and access community support systems.
Goals include sustaining abstinence, preparing for relapse triggers, improving personal health and social functioning, and engaging in continuing care.
October 22, 201519
Residential Services - Today CA’s state plan currently limits residential SUD services to
perinatal beneficiaries Federal matching funds are only available for services provided
in facilities not considered IMDs (i.e. 16 bed max) Ninety percent of California’s residential bed capacity is
considered an IMD No coverage of residential SUD services for non-perinatal
beneficiaries (by Drug Medi-Cal) Limited services offered by some counties using local
resources / federal grant funding
October 22, 201520
Residential Services - Pilot Services are provided to non-perinatal and perinatal
beneficiaries No bed capacity limit (i.e. 16 bed IMD exclusion does not apply) Provided in DHCS licensed & certified residential facilities that
also have been designated by DHCS to meet ASAM treatment criteria
90 day max length of stay for adults; 30 days for adolescents (with one time 30 day extension)
Criminal justice and perinatal pops eligible for longer stays Counties must provide authorization for residential services
within 24 hours of submission of the request
October 22, 201521
County Responsibilities Selective Provider Contracting
Access Selection Criteria Contract Denial / Appeal Process Provider Requirements
Authorization for Residential Beneficiary Access Number (24/7 toll free) Beneficiary Informing (upon first contact) Care Coordination Quality Improvement / Utilization Management County Implementation Plan / Contract
October 22, 201522
Access Each county must ensure that all required services covered
under the pilot are available and accessible to enrollees. If the county is unable to provide services, the county must
cover out-of-network. Access to state plan services (existing benefits) must remain
at the current level or expand upon implementation of the Pilot.
The county shall maintain and monitor a network of appropriate providers that is supported by contracts with subcontractors and sufficient to provider adequate access.
October 22, 201523
Access In establishing and monitoring the network, the county should
consider: Process to require its providers to meet standards for timely
access to care as specified in the county implementation plan and contract
Anticipated number of Medi-Cal eligible clients Expected utilization of services Expected number and types of providers in terms of training
& experience needed Providers accepting new Medi-Cal clients Geographic location of providers
October 22, 201524
Provider Requirements Pilot counties will include the following requirements in their
provider contracts: Provide culturally competent services, including translation services, as
needed. Procedures for coordination of care for enrollees receiving MAT
services. Implement at least two (2) of the following Evidence Based Practices:
Motivational Interviewing Cognitive-Behavioral Therapy Relapse Prevention Trauma-Informed Treatment Psycho-Education
October 22, 201525
Care Coordination Pilot counties must describe care coordination plan for achieving
seamless transitions of care. Pilot county shall enter into a MOU with any health plan that
enrolls beneficiaries served by DMC-ODS. MOU to include: Comprehensive Screening Beneficiary Engagement Shared Plan Development/Treatment Planning Case Management Activities Dispute Resolution Care Coordination/Referral Tracking Navigation Support
October 22, 201526
Quality Each pilot county must have a Quality Improvement (QI) Plan County shall have a QI Committee
Shall review data quarterly County shall have a Utilization Management Program
Must have a system for collecting, maintaining, and evaluating accessibility of care and waiting list information
October 22, 201527
Implementation Plan & Contract Counties must submit to the state a plan for implementation of the
DMC-ODS pilot (boilerplate plan included in STCs). Plan to be approved by both DHCS and CMS. County must also have an executed state/county contract
(intergovernmental agreement) subject to county Board of Supervisors and CMS approval.
At least 60 days prior to CMS contract approval, state shall submit applicable network adequacy requirements for each opt-in county.
Upon approval of the plan and executed contract, counties will be able to bill prospectively for services through this pilot.
October 22, 201528
State Responsibilities Integration Plan Innovation Accelerator Program ASAM Designation for Residential Facilities Provider Appeals Process Monitoring Plan
Annual EQRO Review Timely Access Program Integrity
Reporting of Activity Triennial Report
October 22, 201529
Fiscal Provisions Counties will certify the total allowable expenditures incurred
in providing DMC-ODS pilot services through county operated or contracted providers
Counties will develop proposed county-specific rates for each covered service (except for NTP) subject to state approval
The county will have an opportunity to adjust the proposed rates and resubmit to the state
2011 Realignment requirements related to the Behavioral Health Subaccount will remain in place and the state will continue to assess and monitor county expenditures for the realigned programs
October 22, 201530
Fiscal Provisions Cont. The CMS-approved CPE protocol, based on actual allowable
costs, is still in development and must be finalized before FFP will be made available to the state and counties
The counties may also pilot alternative reimbursement structures subject to standards to be established by the state
Subject to annual state budget appropriation the state also intends to provide payments to participating counties for a state share of the costs for program implementation
October 22, 201531
Evaluation
University of California, Los Angeles, (UCLA) Integrated Substance Abuse Programs will conduct the evaluation
Four key areas of access, quality, cost, and integration and coordination of care
October 22, 201532
Regional Implementation Phase I – Bay Area Phase II – Southern California Phase III – Central Valley Phase IV – Northern California Phase V – Tribal Delivery System
October 22, 201533
Upcoming Events
Statewide SUD ConferenceOctober 26-27, 2015Orange County, CA
http://www.cvent.com/events/substance-use-disorders-statewide-conference/event-summary-4107bbd3082d4f47ad7b6d8f2d28b4e9.aspx
October 22, 201534
Department of Health Care Services
Karen Baylor, PhD, Deputy Director, MHSUD, DHCSMarlies Perez, Division Chief, MHSUD, DHCS
For More Information: http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx
October 22, 201535
Harbage ConsultingDon Kingdon, PhD, Director of Behavioral Health Integration
Molly Brassil, MSW, Deputy Director, Behavioral Health Integration
Courtney Kashiwagi, MPH, Senior [email protected]
October 22, 201536
