Gearing Up Your Organizations (or Not) for Implementing HCBS Services

1. Gearing Up Your Organizations (or Not) for Implementing HCBS Services Presenter: Cindy Freidmutter, CLF Consulting for Supportive Housing Network of New York August 12, 2016

2. Presentation Overview

3. HCBS Services • Psychosocial Rehabilitation (PSR) • Habilitation • Peer Support • Family Support and Training • Education Support • Employment (pre-voc, transitional, ongoing, intensive) • Community Psychiatric Support & Treatment (CPST) • Short-term Crisis Respite • Intensive Crisis Respite

4. Goals for This Session • Identify common challenges SHNNY members will encounter in becoming HCBS providers • Factors to consider in deciding whether or when to proceed with offering HCBS services • Offer an overview of business planning & implementation strategies for launching and sustaining various HCBS services • Flag advocacy issues that are critical to supportive housing providers

5. HCBS 101: Lessons from NYC • Can implement HCBS in Stages: • Certification as an HCBS provider doesn’t mean you have to offer all certified services on day 1 (10/1/16) or ever • OMH will do readiness survey of certified providers, with option to put some or all services on hiatus for a period of time (up to one year in NYC) • Referral of Your Clients or Others Not Assured: • May not get a viable number of clients for the services you plan to provide • Your client can only be referred if agency has contract with MCO • Relationships with lead Health Homes and their downstream care management agencies (CMA) are critical to referrals • Uncertain % of HARP Clients Who Will Receive HCBS: • Assessment & referral for HCBS is a multi-step process that is not ideal for target population; some are not making it through process • Individuals living in certain residential settings (CRs, adult homes) and receiving certain Medicaid services (e.g. PROS, ACT) are ineligible

6. HCBS 101: Lessons from NYC • Financial support available from OMH/OASAS for some costs: • Start-up grants awarded to most agencies, but $ contingent on submitting a viability plan, contracting with MCO & offering one service by the due date • Grants will be awarded for full, partial or upgrade for BHIT platform if agencies contract with 1+ MCOs and complete NYS HCBS surveys • Rates & FFS Structure Big Challenge: • Only reimbursed for face-to-face individual or limited group services • Significant service planning, pre-authorization, documentation and billing mandates that are not reimbursed • Even with MCO pre-authorization, expect only 85% or fewer claims to be paid • NYC rates are not adequate to cover costs; OMH has a rate increase pending at CMS that will better compensate providers especially during start-up

7. Challenges for SH Providers • Supportive housing (SH) contract services overlap with certain HCBS services (e.g. PRS, Habilitation), but as structured HCBS should only supplement, not supplant, SH funding. • HARP enrollees who live in certain residential settings (e.g. CRs, adult homes) will not be able to access HCBS services and services cannot be offered in those settings. • Starting in NYC, OMH is surveying all residential sites to determine site-by-site eligibility for HCBS. • Individuals using PROS, ACT & some other services will not be eligible for many HCBS services. • SH providers are not preferred providers for their tenants; no requirement that clients even get to choose their SH provider. • As HCBS provider, SH agency will get referrals of non-residents/tenants even if current services are housing-focused.

8. Offer HCBS Services or Not: Factors to Consider • Access to eligible population • # of agency clients who are HARP eligible & likely to need/use HCBS services • Opportunities to engage new clients in HCBS services • Start-up/ongoing administrative costs to become HCBS provider • Is agency already a Medicaid provider or will it need to add all needed infrastructure • What are ongoing costs to support Medicaid infrastructure? • How does HCBS fit with agency’s strategic vision • Is patient outcomes likely to improve? • Is building HCBS capacity an agency growth opportunity? • Are there other significant opportunities in same time period? • Timing of HCBS Start-up to Minimize Operating Losses • Can you implement one or several services with low/no additional fixed operating costs? • What are your projections for service demand in start-up year?

9. Business planning for HCBS You need a business plan for each service cluster and for core administrative functions • Project volume of services based on number of HARP eligible in your service area and in your programs. Be conservative • Consider whether you have to build, buy or just adapt Medicaid billing, corporate compliance and QA functions, and at what cost above available NYS start-up & BHIT grants • Calculate revenues and operating costs to see if offering HCBS services is financially viable at a scale you can achieve. Given the fee-for-service rate structure, high fixed costs & uncertainty of referrals, HCBS may not be a viable choice if your agency projects small volume.

10. Implementing PSR: HCBS Manual • Goal: optimally restore the individual’s functional level • Flexibly Delivered: Services may be delivered to individual or group in their home, in the community or at program site like clubhouse • Health Homes are Gatekeeper: Must be in care plan, activities linked to goal achievement and time limited (250 hours annually or 500 with Hab/CPST) • Service Requirements: Utilize (with documentation) evidence-based rehabilitation and recovery practices • Need supervising licensed practitioner (SLP): Workers who provide PSR services should periodically report to a SLP on participants’ progress/re-acquisition of skills (no ratio but other services require 1:10)

11. Implementing PSR: Provider Start-up Plan • No new hires needed-Qualified staff can offer and supervise service delivery • Serve people eligible for & who need PSR-Develop strategy to get agency clients referred • Can deliver services efficiently at existing agency sites or in community-No need to rent space • Upgrading or adding infrastructure is within bandwidth of agency-Can operate with current administrative staff and no significant competing priorities • Will offer other services that clients may also need- In NYC, referrals are targeted to agencies that offer all HCBS services in the individual’s service plan • Can absorb deficits until or unless rates and costs are aligned.

12. Implementing Short-Term Crisis Respite • Plus: Can get direct referrals into program & has potential to save MCOs $. • High fixed costs: Site based with single rooms & 24/7 staff • Will $306 per diem rate (proposed to increase to $476*) cover fixed costs and at what bed count & average occupancy? • Available site aids implementation as no capital available except through recent statewide RFPs • Path to sustainability: Will one or several MCOs contract for all or a % of beds and generate referrals? *89% for upstate counties

13. Common supports that could benefit SHNNY members Three suggestions • Administrative Infrastructure: A cost-effective ASO that can help with billing, corporate compliance, QA, IT and more • Financial Viability: Identify HCBS services & volume that can be most easily implemented by SH agencies and sustained during start-up at break-even or low deficit budget. HCBS may be an outlier where volume actually increases deficits. • Agency culture & staff reorientation: HCBS requires an approach to service delivery that is much closer to clinic operations than supportive housing. Providers might utilize a regional approach to preparing SH agencies for change? What else?

14. Why consider HCBS at all? • Mission-congruent: Residents/tenants will get expanded access to recovery services & best opportunity for agency growth • Financial & program viability varies: Some agencies may be able to develop plans for feasible implementation, including through partnerships • Current rates and processes may change in 2 years: NYS plans on rolling HCBS funds into MCO payment • Future Value Based Payments: If SH providers can show HCBS helps clients fill gaps that are critical to recovery/community stability, they may be in position to benefit from the VBP structure

15. Advocacy issues critical to supportive housing providers Three suggestions • Guidance from DOH and OMH that HCBS supplements, not supplants, SH contract services • Transition to tiered case rate for HCBS sooner than later that focuses on goal attainment • Simplified front-end processes with fewer assessments, plans & MCO authorizations, so clients get timely services they want and need What else?

16. Upcoming HCBS Roll-out • July 1—HARP enrollment started for ROS • October 1-HCBS enrollment starts for ROS • MCTAC-Ongoing provider training • MCOs-available to discuss contracting, billing and other processes • OMH/OASAS-will soon be releasing Readiness Survey & information on BHIT grants (webinars 8/30 at noon and 9/14 at 11am for eligible certified providers. • Providers-still not too late to apply for HCBS certification, but likely too late for start-up grants • SHNNY-Additional technical assistance may be available

17. Important Links • Applying for HCBS Certification: New applicants can get a user ID and passcode to access the system by emailing omh.sm.co.HCBS-Application@omh.ny.gov https://www.omh.ny.gov/omhweb/bho/app-site.html • HCBS Provider Manual https://www.omh.ny.gov/omhweb/bho/hcbs_manual.pdf • Provider Preparation for MCO Billing http://ctacny.org/sites/default/files/5qs-one-sheet-v4.pdf • HCBS Rates http://ctacny.org/media/663#overlay-context=media/662 • More info on BHIT Grants Sharon Bari  - SBari@nyehealth.org & Erica Manganelli - emanganelli@nyehealth.org • MCTAC HCBS Trainings http://www.ctacny.org/search-trainings?title=HCBS&field_date_time_value%5Bmin%5D%5Bdate%5D=&field_date_time_value%5Bmin%5D%5Btime%5D=&field_date_time_value%5Bmax%5D%5Bdate%5D=&field_date_time_value%5Bmax%5D%5Btime%5D=&filter_institute_categories=All&field_training_presenters_tid=All&field_training_keywords_tid=All&op=Apply&form_build_id=form-tVycbZE5tcLf9IF6qJ62GD32GEdckXU8N20MR7f9FRk

18. Remember…

19. Questions & What Next Thank you for participating! Cindy Freidmutter CLF Consulting c.freidmutter@gmail.com 917-554-5599