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Behavioral Heath Solutionsfor Medical Health Plans
Mary Ruiz, President/CEO, Manatee Glens
2014 Guide to Behavioral Health Conference
Orlando Florida
Florida’s MedicaidManaged Medical Assistance
Florida’s General PlansManaged Medical Assistance
• Amerigroup (Wellpoint)• Better Health (PSN) • Coventry (Aetna)• First Coast Advantage• (PSN Shands) • Humana • Integral (PSN FQHC)• Molina
Florida’s General PlansManaged Medical Assistance
• Preferred Medical (HMO)
• Prestige (Blue Cross) • SFCCN (PSN) • Simply (HMO) • Sunshine (Centene)• United Health • Staywell (Wellcare)
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)
Florida’s MedicaidManaged Medical Assistance
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
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
Florida’s MedicaidManaged Medical Assistance
Access Standards
No Wait List
Urgent One Day
Sick Care One Week
Well Care One Month
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
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
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
Provider Challenges
• Lower Rates• Increased Utilization
Management• Staff Attrition to Plans• Increased Admin Costs• Decreased Cash Flow• Lower Collection Rates• Inclusion in Networks
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
New Possibilities?
• Pay for Performance• Primary Care
Coordination• Telemedicine• Substitute Services• Healthy Behaviors• Mental Health
Excellence Act
Pay for Performance
System
• Does it improve outcomes?
• How can outcomes differ if plan is the same?
• What are the right payment models?
Provider
• What is the real total cost of care?
• Does the data bear up?
• What innovations are needed to move outcomes?
Florida MMA Contracted Quality Measures
DepressionStrategies Care, screening, or test
Pharmacy/Lab Reports
Peer Support
Psycho Education
Medication Management
Care Management
Cognitive Behavioral
Adults newly diagnosed with depression and treated with an antidepressant who received the following:
Effective acute phase: filled sufficient number of Rx to allow for 84 days of continuous therapy.
Effective continuation phase: filled sufficient number of Rx to allow for 180 days of continuous therapy.
To qualify as a new diagnosis, 2 criteria must be met:
A 120-day (4 month) negative diagnosis history on or before the start date and a 90-day (3 month) negative medication history on or before the start date
Florida MMA Contracted Quality Measures
Mental illnessStrategies Care, screening, or testPharmacy/Lab ReportsFamily Education
Medication Management
Care Management
Parenting Support
Respite
Children 6-12 years who received an initial prescription for ADHD medication and:
Received at least one follow-up visit with a prescriber within 30 days of initiation of medication
Remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two more follow-up visits between four weeks and 9 months
Florida MMA Contracted Quality Measures
Alcohol and other drug dependenceStrategies Care, screening, or test
Intervention
Outreach
Harm Reduction
Motivational Enhancement
Peer Support
Medication Assisted Therapy
Patients 13 and older diagnosed with alcohol and other drug dependence who:
initiate treatment within 14 days of diagnosis
receive two additional AOD services within 30 days of initiation
Florida MMA Contracted Quality Measures
Mental illnessStrategies Care, screening, or test
Care Management
Respite
Peer Support
Recovery Plan
Family Education
Patients 6 and older discharged from an inpatient mental health admission and receive:
One follow-up encounter with a mental health provider within 7 days after discharge.
One follow-up encounter with a mental health provider within 30 days after discharge.
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
Pay for PerformancePayment Models
Payment Model
Enhanced Rate
Monthly Cap Rate for Care Management
Monthly Bundled Payment for Treatment
Capitation
Precedence
Mental Health Excellence
HMO Primary Care
Florida BNET
Prepaid Mental Health Plans
Pay for PerformancePayment Models
Payment Model
Enhanced Rate
Monthly Cap Rate for Care Management
Monthly Bundled Payment for Treatment
Capitation
Performance TargetsAccess to Care
Adherence or High Risk
High Cost
Medical Home
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
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
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
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
Primary Care Coordination
Plan
Demonstration
Projects
• Body Mass Index • Immunization Status• HbA1c Levels• Blood Pressure• Risk Identification• Functional Outcomes• Medication Compliance
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
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
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
Substitute Services
1. Plan Request
2. AHCA Approval
3. 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
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
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
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
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
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
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
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
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
Mental Health Excellence ActClinic Certification
Requirements
1. Staffing
2. Access
3. Care Coordination
4. Scope of Services
5. Quality
6. Nonprofit/Government
Mental Health Excellence Act
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 LevelBetter align MMA with Excellence ActFlorida secures planning grant
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
The Finish Line
