1 California’s Changing Mental California s Changing Mental Health System Behavioral Health Care Symposium Behavioral Health Care Symposium December 6, 2011 Sheree Kruckenberg Vice President, Behavioral Health California’s Changing Mental Health System Agenda Bridge to Reform The 1115 Waiver Behavioral Health Assessment Seniors & Persons with Disabilities Dual Eligibles (Medi-Medi) 2 Realignment DMH and DADP Elimination Mental Health Medi-Cal Reassigned to DHCS Drug Medi-Cal Reassigned to DHCS
Transcript
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California’s Changing MentalCalifornia s Changing Mental Health System
Behavioral Health Care SymposiumBehavioral Health Care SymposiumDecember 6, 2011
Sheree KruckenbergVice President, Behavioral Health
California’s Changing Mental Health System
Agenda Bridge to Reform
The 1115 Waiver
Behavioral Health Assessment
Seniors & Persons with Disabilities
Dual Eligibles (Medi-Medi)
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Realignment
DMH and DADP Elimination
Mental Health Medi-Cal Reassigned to DHCS
Drug Medi-Cal Reassigned to DHCS
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Bridge to Reform
The 1115 WaiverThe 1115 Waiver 1115 waiver & plan for Medicaid expansion in 2014
Objective is to assist the Medicaid substance use and mental health systems to prepare for:
Eligibility expansion
Physical health integration
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While assuring:
Quality
Effectiveness
Integrity
Bridge to Reform
The 1115 Waiver Need to have a vision for what the system
can do
should do
assess the gaps between where the system is now and where we want it to be
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Need to focus on Medicaid expansion population and services; unserved and underserved people; gap-filling service modalities and provider capacity to serve new populations under different conditions, not just on the current Medicaid program
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California’s 1115 Waiver Behavioral Health Assessment
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California’s 1115 Waiver Behavioral Health Assessment
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California’s 1115 Waiver Behavioral Health Assessment
Quantify the Universe of Substance Use and Q yMental Health Service Providers Use Medicaid Provider Identification Numbers (PINs)
to tabulate providers by service type(s) and county
Identify multi-service and single service providers and practitioners
D id i i b b f i i
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Document provider activity by numbers of participants served and volumes of services delivered
Collect information on providers in state or county substance use or mental health systems, not all of which will also be Medicaid providers
California’s 1115 Waiver Behavioral Health Assessment
Project Timeline
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California’s 1115 Waiver Behavioral Health Assessment
M di id E i P l tiMedicaid Expansion Population Need for special engagement/outreach strategies to
enroll difficult to engage populations.
Specific populations of concern:
Persons experiencing homelessness
Persons with substance use disorders and/or
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Persons with substance use disorders and/or mental illness
Prison release population
Persons whose primary language is not English
California’s 1115 Waiver Behavioral Health Assessment
DHCS W b d E ilDHCS Web and Email DHCS Behavioral Health Needs Assessment & Plan:
California’s 1115 Waiver Behavioral Health Assessment
CHA’ CCHA’s Concerns See June 15, 2011, letter to DHCS
See November 10, 2011, email to DHCS
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Seniors & Persons with Disabilities (SPD)
B k dBackground
Beginning June 2011, the Department of Healthcare Services began enrolling Seniors and Persons with Disabilities into managed care in 16 counties.
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Mandatory enrollment on enrollee’s birthday
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Seniors & Persons with Disabilities (SPD)
E ll t S D fi itiEnrollment Summary Definitions
Total Enrolled: the number of transitional SPDs enrolled during their birth month
Chose Plan: the number of transitional SPDs who chose the plan they wanted to
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enroll in during their birth month
Seniors & Persons with Disabilities (SPD)
E ll t SEnrollment Summary
June 2011 July 2011 Aug. 2011 Sept. 2011
Total Enrolled 23,743 22,754 24,345 20,396
Chose Plan 8,763 9,052 9,419 8,129
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Seniors & Persons with Disabilities (SPD)
C ti I l d d i th ChCounties Included in the Change
Alameda Contra Costa Fresno Kern
Sacramento San Bernardino San Diego San Francisco
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Kings Los AngelesMadera Riverside
San Joaquin Santa Clara Stanislaus Tulare
Seniors & Persons with Disabilities (SPD)
FFS Medi-Cal Only SPD by Age GroupsIn Two-Plan and GMC Managed Care Counties
(as of May 2010)
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Seniors & Persons with Disabilities (SPD)
P l N t I l d d i th ChPeople Not Included in the Change
Dual Eligibles, or those with Medicare Foster Children Identified as Long Term Care (LTC) Those with Other Health Insurance Share of Cost (SOC) Medi-Cal
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Share of Cost (SOC) Medi Cal California Children’s Services (CCS) –
Although currently excluded, this group may become mandatory in the future
Dual Eligibles (Medi-Medi)
D t ti B k d d PDemonstration Background and Process CA Legislature directed DHCS in 2010 to create
new models of coordinated care delivery for dual eligibles
SB 208 (Steinberg) calls for demonstrations in four counties
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four counties
About 1 in 7 Medi-Cal enrollees are dual eligibles
These account for nearly 25% of State spending on Medical
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Dual Eligibles (Medi-Medi)
California Duals Demonstration OverviewCalifornia Duals Demonstration Overview Approximately 1.1 million enrolled in both
Among the highest-need /cost users of health care services
Planned 3-year demonstration for launch at the end of 2012
Will examine the benefits of coordinated care by enrolling a portion of dual eligibles into coordinated health care
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a portion of dual eligibles into coordinated health care delivery models
Hopes to drive coordinated and streamlined delivery of the full continuum of services that dual eligibles need, while better managing costs
Dual Eligibles (Medi-Medi)
Medicare & Medi Cal Expenditures for Dual Eligibles 2007Medicare & Medi-Cal Expenditures for Dual Eligibles - 2007
Expenditures Enrollment Per Capita Cost
Disabled $5.45 billion 395,808 $13,770
Aged $11.4 billion 511,030 $22,306
Blind $247 million 12,754 $19,333
LTC $3.75 billion 67,803 $55,321
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Other $148 million 23,364 $5,831
TOTAL $21 billion 985,383 $21,396
Source: DHCS RASS using Medicare and Medi-Cal aid claims data from Jan 1, 2007 – Dec. 31, 2007
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Dual Eligibles (Medi-Medi)
D l D t ti S f M d lDuals Demonstration Scope of Models
Demonstration will involve models through which one entity is coordinating care for the total needs of a person –medical and social. This includes
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behavioral health, social supports, medical care and long term care
Dual Eligibles (Medi-Medi)
D l D t ti G lDuals Demonstration Goals Improve beneficiaries’ quality of life, health care
and satisfaction with the health care system
Identify and eliminate existing sources of fragmentation and inefficiencies that result from the incongruities between both programs
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the incongruities between both programs
Develop financial models that drive streamlined and coordinated care through shared savings and the elimination of cost shifting
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Dual Eligibles (Medi-Medi)
D l D t ti G lDuals Demonstration Goals Create one point of accountability for the
delivery, coordination and management of the full continuum of needed services
Promote and measure improvements in health outcomes
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outcomes
Slow the cost growth in Medi-Cal and Medicare, as possible
Dual Eligibles (Medi-Medi)
Dual Eligibles by County – July 2010
County Dual Eligibles % of State’s DualsLos Angeles 370,785 32.9%
San Diego 75,019 6.7%
Orange 71,188 6.3%
San Bernardino 52,621 4.7%
Santa Clara 49,420 4.4%
Riverside 49,088 4.4%
Alameda 46.630 4.1%
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Source: Research and Analytic Studies Section, DHCS
Sacramento 44,806 4.0%
San Francisco 44,669 4.0%
Fresno 31,153 2,8%
Kern 24,616 2,2%
Remaining 47 Counties 266,708 23.7%
TOTAL 1,126,703 100.0%
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2011 Realignment
E ti lEssentials
Part of 2011-12 budget plan
Provides 6.3 billion to local governments (primarily counties) for 2011-12
Funds for criminal justice, mental health
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Funds for criminal justice, mental health and social services
Ongoing funds thereafter
2011 Realignment
Major Elements of Realignment at Different Stages
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2011 Realignment
Expenditures for 2011 Realignment (in millions)
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2011 Realignment
Revenues for 2011 Realignment (in millions)Revenues for 2011 Realignment (in millions)
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2011 Realignment
State’s Role and Funding ResponsibilitiesState s Role and Funding Responsibilities
State’s role will diminish as local government responsibilities increase
Legislature may still desire state agencies to retain some roles, e.g.:
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Program oversight
Technical assistance
Statewide coordination
Ensuring federal conformity
2011 Realignment – Detailed Descriptions of Realigned Programs
R li d C i i l J ti PRealigned Criminal Justice Programs Adult offenders and parolees
Court security
Pre-2011 juvenile justice realignment
A variety of local public safety grant
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y p y gprograms
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2011 Realignment – Detailed Descriptions of Realigned Programs
Ad lt Off d & P l ($1 59 Billi )Adult Offenders & Parolees ($1.59 Billion) Changes are projected to reduce state inmate
population by about 14,000 inmates in 2011-12 and nearly 40,000 upon full implementation in 2014-15
State parolee population is expected to decline by about 25 000 parolees in 2011-12 and 77 000 (about
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about 25,000 parolees in 2011 12 and 77,000 (about 75% of total parole population) in 2014-15
2011 Realignment – Detailed Descriptions of Realigned Programs
H lth d H S i PHealth and Human Services Programs Increases county funding responsibility for:
Mental Health Managed Care (MHMC)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
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Drug and alcohol programs
Foster Care and Child Welfare Services (CWS)
Adult Protective Services (APS)
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2011 Realignment – Detailed Descriptions of Realigned Programs
M t l H lth M d C ($184 Milli )Mental Health Managed Care ($184 Million)
In 2011-12, about $184 million of Mental Health Services Act (MHSA) funds to be redirected and used in lieu of General Fund on a one-time basis to support MHMC
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2011 Realignment – Detailed Descriptions of Realigned Programs
Drug and Alcohol Programs ($184 Million)g g ( )
Realigns several substance abuse treatment programs previously funded through the Dept. of Alcohol and Drug Programs (DADP)
Provision of services has long been administered primarily at the county level
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Major substance abuse programs realigned are:
Regular and Perinatal Drug Medi-Cal
Regular and Perinatal Non-Drug Medi-Cal
Drug Courts
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2011 Realignment – Detailed Descriptions of Realigned Programs
R l d P i t l D M di C lRegular and Perinatal Drug Medi-Cal Provides services to Medi-Cal beneficiaries
Services include:
Outpatient drug free services
Narcotic replacement therapy
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Day care rehabilitative services
Residential services for pregnant and parenting women
2011 Realignment – Detailed Descriptions of Realigned Programs
Drug CourtsDrug Courts Link supervision and treatment of drug users with
ongoing judicial monitoring and oversight
Several types of drug courts, including:
Dependency drug courts – focus on cases involving parental rights
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g p g
Adult drug courts – focus on convicted felons or misdemeanants
Juvenile drug courts – focus on delinquency matters involving substance-using juveniles
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DMH and DADP Elimination
Ch D t R li tChanges Due to Realignment
Eliminate the Department of Mental Health (DMH)
Eliminate the Department of Alcohol and Drug Programs (DADP)
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Create a Department of State Hospitals
DMH and DADP Elimination
Eli i t th D t t f M t l H lthEliminate the Department of Mental Health Responsibilities for EPSDT and MHMC transfer
to counties
Remaining state-level responsibilities transfer to DHCS during 2011-12
With the creation of Dept of State Hospitals
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With the creation of Dept. of State Hospitals, DMH will have few functions remaining
2012-13 Governor’s Budget will include proposal on where these functions are to go
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DMH and DADP Elimination
Eliminate the Department Alcohol and Drug Programs Responsibilities for Drug Medi-Cal transfer to counties
State functions necessary for operation of Drug Medi-Cal will go to DHCS
DADP will be left with some federal block grants, licensing prevention and counselor and certification
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licensing, prevention and counselor and certification programs
These functions can be shifted to another department
2012-13 Governor’s Budget will address remaining components
DMH and DADP Elimination
Create Department of State Hospitals State hospitals currently under the oversight of DMH, which
will be eliminated
State hospitals have undergone changes in recent years
Most patients are no longer civil commitments, but forensic
Courts have required accelerated activation of treatment facilities and increasing admissions
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c es d c e s g d ss o s
State hospitals have been operating under a consent judgment with the federal government to change the model of providing services to patients
Department of State Hospitals will focus efforts on addressing necessary changes in the new environment
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Mental Health Medi-Cal Reassigned to DHCS
B k dBackground Transfer of services from DMH authorized by
2011-12 State Budget and AB 102 & AB 106
State responsibility for administering MHSA altered by AB 100
2011 12 May Revise of Budget eliminates DMH
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2011-12 May Revise of Budget eliminates DMH and ADP in FY 2012-13
Mental Health Medi-Cal Reassigned to DHCS
Other Changes Required by LegislationOther Changes Required by Legislation Eliminate state level review and approval of county
plans and expenditures by DMH and Mental Health Services Oversight and Accountability Commission (MHSOAC)
Replace DMH with MHSOAC in providing technical
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assistance to county Mental Health Plans
Reduce amount of revenues available from MHSA for State administration from 5% to 3.5%
Click on “Information Regarding the DHCS/DMH Medi-Cal Transfer, Summer Stakeholder, and Realignment” under the “What’s New?” section (meeting notices, info and updates)
Facebook – CA Community Mental Health Stakeholder www.facebook.com/pages/CA-Community-Mental-Health-
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Stakeholder/179811872085830
Twitter - @CAMHStakeholder
Email [email protected] If you’d like your comments posted to the DMH site, indicate your
permission in your email message
Mental Health Medi-Cal Reassigned to DHCS
DMH Transition Stakeholder Input Timeline
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Mental Health Medi-Cal Reassigned to DHCS
Transition Plan AB 102 requires DHCS to submit a written transition plan
(see http://www.dhcs.ca.gov/services/medi-cal/Pages/MHTransitionPlan.aspx)
DHCS must coordinate with DMH and hold stakeholder meetings to guide the development of the plan
Transfer of functions must not interrupt service delivery
Pl l id b k d f M di C l ’
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Plan also provides background of Medi-Cal program’s delivery of mental health services and roles played by DMH and DHCS
DHCS will submit bi-monthly updates on transition plan to the Legislature and a final update by May 15, 2012
Mental Health Medi-Cal Reassigned to DHCS
Transition Plan will Ultimately: Improve access to culturally appropriate community-
based mental health services, including:
Focus on client recovery
Social rehabilitation services
Peer support
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Effectively integrate the financing of services, including the receipt of federal funds, to more effectively provide services
Improve state accountabilities and outcomes
Provide focused, high-level leadership for behavioral health services within the state administrative structure
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Mental Health Medi-Cal Reassigned to DHCS
AB 102 All regulations and orders concerning Medi-Cal specialty mental
health managed care remain in effect and fully enforceable unless and until readopted, amended or repealed by DHCS, or until they expire
Providers can rely upon existing guidelines until DHCS takes definitive action
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DHCS need not complete major overhauls to regulations or other policies in order to meet July 1, 2012, deadline
Administration is committed to making sure the program is transferred successfully and – with stakeholder input – will then examine possibilities of refinements, improvements and efficiencies
Mental Health Medi-Cal Reassigned to DHCS
Deputy Director Recruitmentp y DHCS began recruitment for new Deputy Director in
September 2011 (http://www.dhcs.ca.gov/services/medi-cal/Pages/Medi-
CalMentalHealth.aspx and click on “Duty Statement” under the recruitment announcement)
New Deputy Director will be in place before July 1, 2012
Within 30 days of appointment, Deputy Director will oversee the recruitment of the Chief for the Mental Health
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Services Division
By March 2012, DHCS and DMH will identify appropriate national organizations and enroll Deputy Director in them to ensure appropriate representation for California
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Mental Health Medi-Cal Reassigned to DHCS
New DHCS Structure Adding new Deputy Director of Mental Health and
Substance Use Disorder Services Will report to DHCS Director
Incumbent will be Governor appointee; require Senate confirm
Will oversee two new organizations:
M t l H lth S i Di i i /Offi
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Mental Health Services Division/Office
Substance Use Disorder Treatment Services Division/Office
Reporting structure replicates oversight responsibilities of the other three program Deputy Directors at DHCS.
Two new organizations will operate independently, but will benefit from co-location to facilitate integration of services
Mental Health Medi-Cal Reassigned to DHCS
Functions to Transfer by December 2011 Claims Processing Cost Settlements Fiscal Audit Processes and Overlaps Chart Audits (EPSDT, adult &
inpatient) and Appeals System Review Program Protocols
and Program Audits Annual EQRO Reviews
Assessment and Referral of Questionable Medi-Cal Billings
IT Support for Medi-Cal Systems and Sub-Systems
PASRR LV I and LV II Evaluations 2nd Level TAR Appeals and TAR
Lawsuits Medi-Cal Clinic Certifications and
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Creation of Estimates and Related Budget
Ombudsman Processes County Technical Assistance
Processes Specialty Mental Health Data
Management and Support
Re-Certifications Professional Licensing Waivers Establishment and Maintenance of
Provider Files Develop Timelines for Flowcharting
the Above Items …and more
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Mental Health Medi-Cal Reassigned to DHCS
Policy Reviews By June 2012, establish workgroups of staff and
stakeholders to review the following and identify need for revision and updates, clarification, repeal, etc.:
Title 9 and Title 22 of the CA Code of Regulations
Federal regulations and laws to clarify requirements
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State laws
DMH policy letters/information notices
Identify and monitor all active relevant mental health legislation
Develop timelines for implementation
Mental Health Medi-Cal Reassigned to DHCS
Workload Prior to April 2012, identify critical outstanding
workload. A few examples include: Fiscal audits & cost settlements
Ad i i t ti F ti C tlAdministrative Functions Currently Performed by DMH Impacting Hospitals
Medi-Cal Program Compliance
Chart Reviews
TAR Appeal Reviews and Lawsuits
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Annual License Review
Criminal Background Checks
Section 5150 Facilities
Annual Certifications
Drug Medi-Cal Reassigned to DHCS
AB 106 Transfer of Department of Drug and Alcohol Programs
(DADP) functions to DHCS shall not have unintended interruptions in service delivery
Transfer is intended to:
Improve access to alcohol and drug treatment services, including a focus on recovery and rehabilitation services
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More effectively integrate the financing of services, including the receipt of federal funds
Improve state accountability and outcomes
Provide focused, high level leadership for behavioral health services
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Drug Medi-Cal Reassigned to DHCS
Drug Medi-Cal Treatment ProgramDrug Medi Cal Treatment Program DADP contracts with counties and direct service
providers for services
County participation in the program is optional
Counties may provide services directly or subcontract with other providers
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p
All but about 15 counties currently have program
If a county opts out and a certified provider in the county wishes to provide services, DADP executes a service contract directly with provider
Drug Medi-Cal Reassigned to DHCS
D M di C l T t t PDrug Medi-Cal Treatment Program Five covered services for the program are:
Day Care Rehabilitation Treatment
Outpatient Drug Free Services
Perinatal Residential Substance Abuse T
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Treatment
Naltrexone Treatment Services
Narcotic Treatment Services
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Drug Medi-Cal Reassigned to DHCS
“Regular” Medi-Cal CoverageRegular Medi Cal Coverage The Medi-Cal Provider Manual identifies “regular” fee-for-
service Medi-Cal alcohol or drug treatment services provided outside of the program
The Manual also offers guidance to providers of drug/alcohol services for Medi-Cal beneficiaries
“R l ” M di C l i h h i d t
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“Regular” Medi-Cal covers services such as heroin detoxonly on an inpatient basis and only as a result of a serious medical complication (e.g., overdose) or concurrent medical conditions that alone or in combination with addiction would require hospitalization (e.g., severe acute hepatitis)
Drug Medi-Cal Reassigned to DHCS
“Regular” Medi-Cal Coverageg g Acute hospitalization coverage will terminate when the
associated medical problems can be treated at a lower level of care or on an outpatient basis
Medi-Cal will not cover acute hospitalization solely for completion of a detox course
Medi Cal Managed Care plans exclude from their
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Medi-Cal Managed Care plans exclude from their contracts all services available under the Drug Medi-Cal Treatment Program as well as outpatient therapies listed in the Provider Manual as alcohol/substance abuse treatment drugs reimbursed through the Medi-Cal fee-for-service program
