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Molly Brassil, Associate Director, Public Policy, California Mental Health Directors Association

Health Care Reform Implementation Highlights Relevant to California’s Public Mental Health & Substance Use Disorder System Presentation to NACBHDD Board Meeting October 29, 2012. Molly Brassil, Associate Director, Public Policy, California Mental Health Directors Association

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Molly Brassil, Associate Director, Public Policy, California Mental Health Directors Association

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  1. Health Care ReformImplementation Highlights Relevant to California’s Public Mental Health & Substance Use Disorder SystemPresentation to NACBHDD Board MeetingOctober 29, 2012 Molly Brassil, Associate Director, Public Policy, California Mental Health Directors Association Tom Renfree, Executive Director, County Alcohol and Drug Administrators Association of California Robin Kay, Chief Deputy Director, Los Angeles County Department of Mental Health Louise Rogers, Deputy Chief, San Mateo County Health System Scott Gruendl, Director of Health Services Agency, Glenn County

  2. Presentation Outline • Overview of California’s Public Mental Health System • Overview of California’s Public Substance Use Disorder System • Managed Care in California • California’s Bridge to Reform 1115 Waiver – Low Income Health Program • Coordinated Care Initiative – California’s Dual Eligibles Demonstration • California Health Benefit Exchange • Benchmark for Individual & Small Group Market • Behavioral Health Service Plan • Local Implementation Activities: • Los Angeles County (large county example) • San Mateo County (medium county example) • Glenn County (small county example)

  3. California’s Public Mental Health System • Under the provisions of our Medicaid Title 42, Section 1915(b) “freedom of choice” waiver covering the mandatory enrollment of eligible Medi-Cal beneficiaries in the Mental Health Plans (MHPs) for specialty mental health, emergency and hospital services, California’s county MHPs are considered prepaid inpatient health plans. • California’s MHPs are responsible for assuring 24 hour, seven day/week access to emergency, hospital and post-stabilization care for the covered psychiatric conditions for Medi-Cal beneficiaries.

  4. California’s Public Mental Health System • In addition, California has two approved state plan amendments (SPA) that increase the scope of outpatient, crisis and residential and inpatient mental health coverage provided to Medi-Cal beneficiaries when medically necessary, by the MHP. • California’s Approved State Plan Amendments: • Targeted case management for persons with mental illness. • Mental health services available under the Rehabilitation Option, broadening the range of personnel and locations that were available to provide services to eligible beneficiaries.

  5. California’s Public Mental Health System • MHPs are subject to CFR Title 42, Part 438 Managed Care requirements which specify additional access, beneficiary protection and quality management requirements that the MHP must conform to. • Both federal and state code and regulation specify that there is to be a contract between the state and the MHP/PIHP specifying the conditions under which the managed care program will operate. • The regulations and contract also specify requirements for the coordination of health and mental health treatment between the county and the state contracted health plans, including that an MOU be in place between the county and each health plan specifying the process for timely referral and treatment.

  6. California’s Public Substance Use Disorder System • Substance Use Disorders (SUD) constitute substantial health problems, and they also cause or contribute to other serious health conditions or complicate treatment for other conditions. Along with mental illnesses, substance use disorders drive many of the costs and caseloads in child welfare & criminal justice systems, hospitals, ERs and other health care systems. • In California, the public system of care for the prevention and treatment of SUD is overseen by a single state agency (which until July of 2013 is the State Department of Alcohol & Drug Programs), but is administered by counties, which either provide services directly or (in most cases) contract with private providers for services. • Public treatment of SUD is predominantly provided in separate specialty services programs, some of which are based on social-model recovery (i.e. 12-step), and others which offer medication-assisted treatment (i.e. methadone maintenance).

  7. California’s Public Substance Use Disorder System • SUD treatment is typically provided by staff members who are state-certified but not professionally licensed. • Traditional sources of funding for public SUD services: • Federal Substance Abuse Prevention & Treatment Block Grant. • FFP for Drug Medi-Cal • State General Fund (now Realignment funding) for: • Drug Medi-Cal Match • Perinatal Services • Drug Court Treatment Programs • Drug Medi-Cal (D/MC) was originally a set of benefits within Short-Doyle Medi-Cal. The two systems separated in the late seventies, but still today are linked in the billing process at the state level.

  8. California’s Public Substance Use Disorder System • At the state level in California, D/MC is a fee-for-service Medi-Cal specialty carve out. Services reimbursed by D/MC must be medically necessary and provided by or under the direction of a physician. Specific benefits are the following: • Narcotic Treatment Program (NTP) – Outpatient treatment primary utilizing methadone • Outpatient treatment utilizing the long-acting narcotic antagonist Naltrexone • Outpatient Drug Free – Mostly group counseling and some limited individual counseling • Day Care Rehabilitative – Intensive outpatient treatment, including group and individual counseling, eligibility for which is limited to pregnant and postpartum women and, as an EPSDT benefit, to children under 21. • Perinatal Residential – Residential treatment provided to pregnant and postpartum women in facilities of 16 beds of less, not including beds occupied by children. (Room & board must be paid for by revenue other than D/MC.)

  9. Managed Care in California • As of October 2012, approximately 4.8 million Medi-Cal beneficiaries in 30 California counties receive their health care through three models of managed care: Two-Plan, County Organized Health Systems and Geographic Managed Care. • As part of the 1115 waiver, California recently completed a yearlong transition to mandatorily enroll most Seniors and Persons with Disabilities in managed care (some exemptions). • Beginning in June 2013, California plans to expand managed care into rural areas (28 counties) that are now Fee-For-Service only. • Subject to legislative approval, California intends to expand the Coordinated Care Initiative (Duals Demonstration) to all counties in the state

  10. California’s Bridge to Reform Section 1115(a) Medicaid Demonstration • The California Department of Health Care Services (DHCS) received approval in November 2010 for the Section 1115(a) Medicaid Demonstration, entitled “California’s Bridge to Reform.” • The demonstration is effective November 1, 2010, through October 31, 2015. • Through the Section 1115 waiver, California intends to advance Medi-Cal program changes that will help the state transition to the federal reforms that will take effect in January 2014. • Changes under the waiver involve expanding coverage today for those who will become “newly eligible” in 2014 under health care reform, implementing models for more comprehensive and coordinated care for some of California’s most vulnerable residents, and testing various strategies to strengthen and transform the state’s public hospital health care delivery system.

  11. Low Income Health Program • The Low Income Health Program (LIHP) is a new, optional program established under the waiver that is being implemented at the county level in California to expand coverage to eligible low-income adults. • LIHP is available to adults between 19 and 64 years of age who are not eligible for Medi-Cal or the Children’s Health Insurance Program, are not pregnant, are within the county’s income requirements, meet county residency requirements, and meet federal citizenship and immigration verifications and restrictions. • The LIHP builds on California’s existing ten-county Coverage Initiative program by offering participation to all counties in the state. • County LIHPs will be effective July 1, 2011 through December 31, 2013, at which time the majority of enrollees will become Medi-Cal eligible under the ACA expansion.

  12. Low Income Health ProgramEligibility • The Medicaid Coverage Expansion (MCE) portion of LIHP is for those individuals who have family incomes at or below 133% of the federal poverty level (depending on participating county income standards) • The Health Coverage Initiative (HCCI) portion of LIHP is for those individuals who are not insured and have family incomes above 133% through 200% of the federal poverty level (depending on participating county income standards) • It is possible for a county to offer the MCE portion but not the HCCI portion • The upper income limit in either the MCE or HCCI may vary by county and those counties who do not offer HCCI may lower the upper income limit in MCE below 133%.

  13. Low Income Health ProgramCore Benefits • The LIHP offers two sets of core benefits – one portion for the MCE portion and one for the HCCI portion • Among the MCE core benefits are minimum mental health services that must be offered to MCE-eligible enrollees • According to the Special Terms and Conditions of the wavier, “the state must offer a minimum evidence-based benefits package for mental health services under the Demonstration to promote services in community-based settings with an emphasis on prevention and early intervention.” • SUD services are NOT included as a required core MCE benefit. • However, each LIHP may choose to include additional benefits (as approved by CMS) as part of the core benefit offering, such as expanded mental health services and/or substance use disorder treatment. Several counties have opted to include expanded MH or SUD services in the benefit package for LIHP enrollees.

  14. Low Income Health ProgramMental Health Benefits • Each participating county must, at minimum, provide: • Up to 10 days/year of acute inpatient hospitalization in an acute care hospital, psychiatric hospital, or psychiatric health facility • Psychiatric pharmaceuticals • Up to 12 outpatient encounters per year. Outpatient encounters include assessment, individual or group therapy, crisis intervention, medication support and assessment. If a medically necessary need to extend treatment exists, the LIHP may optionally expand services • County may opt to provide mental health services through a delivery system that is separate from the LIHP – i.e. “carve out mental health services”

  15. Coordinated Care Initiative – California’s Duals Demonstration • The Duals Demonstration will involve models through which one entity is coordinating care for the total needs of a person – medical and social. • The demonstration will expand the managed care benefits for selected demonstration health plans to include the In-Home Supportive Services (IHSS) program, as well as Multipurpose Senior Services Programs (MSSP), Community-Based Adult Services, and skilled nursing facility services as part of the blended capitated rate to the participating managed care organizations. • While county-administered Medi-Cal mental health and substance use disorder services are not to be initially included in the health plans’ blended capitated rate, demonstration plans will be charged with managing the entire Medicare benefit, including mental health services covered by the Medicare program.

  16. Coordinated Care Initiative – California’s Duals Demonstration • Contingent on CMS approval, the demonstration is slated to begin June 2013. • The 8 selected demonstration counties are Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara. • County mental health & SUD priority areas for further consideration include risk and cost shifting concerns, information exchange barriers and opportunities, payment policies, conflict resolution, network coordination, performance measures and shared savings opportunities, MOU elements, among others. • The state is currently developing a shared accountability framework to incentivize coordination between MHPs/SU administrators and demonstration health plans

  17. California Health Benefit Exchange • California was the first state in the nation to enact legislation creating a health benefit exchange under federal health care reform. • California’s Exchange is an independent public entity within state government with a five-member board appointed by the Governor and the Legislature. • The federal government awarded California $1 million to fund preliminary planning efforts related to the development of an exchange. In August 2011, the California Health Benefit Exchange received a $39 million Level I Exchange Establishment grant to help the state plan for and design the Exchange and to recruit necessary technical and support staff. • The Exchange is currently preparing to submit a new Federal Establishment Grant application to support California’s ongoing planning work. • After 2014, the Exchange must be self-supporting from fees paid by health plans and insurers participating in the Exchange.

  18. California Health Benefit Exchange • The Exchange Board meets monthly in both closed and public sessions to tackle a host of issues in preparation for a January 1, 2014 marketplace launch. • The Exchange anticipates that final Qualified Health Plan (QHP) selection shall be completed by May 31, 2013. • Open enrollment for Qualified Health Plans is anticipated to begin next fall. • CMHDA and CADPAAC continue to provide comments alongside our coalition partners to raise MH/SUD considerations

  19. California Health Benefit Exchange • Current Exchange Priorities: • Marketing and branding • Outreach • Premium aggregation and agent payment options • Small Business Health Options Program (SHOP) • Qualified Health Plan policies and contracting • Service Center • Consumer Assistance/Ombudsman Program

  20. Essential Health Benefits for the Individual and Small Group Market • California’s Governor Brown recently signed complementary Senate (SB 951 – Hernandez) and Assembly (AB 1453 – Monning) bills requiring an individual or small group health care service plan contract or health insurance policy that is issued, amended or renewed in California on or after January 1, 2014 to at minimum include coverage for essential health benefits. • This coverage requirement applies to individual and small group plans/policies offered to consumers and small businesses both inside and outside of the California Health Benefit Exchange. • The legislation selects a Kaiser small group product as California’s reference (“benchmark”) plan.

  21. Mental Health Benefits in the Benchmark Plan • According to the Evidence of Coverage (EOC) for the identified benchmark plan, coverage should include services and benefits for a broad range of mental health conditions, utilizing the mental disorder definition as supplied by the DSM-IV-TR. • According to the EOC, mental health services are covered “…only when the services are for the diagnosis or treatment of mental disorders. A mental disorder is a mental health condition identified as a mental disorder in the DSM-IV-TR that results in clinically significant distress or impairment of mental, emotional, or behavioral functioning.” • Coverage is not limited to a specific list of conditions or diagnoses.

  22. Mental Health Benefits in the Benchmark Plan • Outpatient Mental Health Services: • Individual and group mental health evaluation and treatment • Psychological testing when necessary to evaluate a mental disorder • Outpatient services for the purpose of monitoring drug therapy • Inpatient & Intensive Psychiatric Treatment: • Inpatient psychiatric hospitalization • Short-term hospital-based intensive outpatient care (partial hospitalization) • Short-term multidisciplinary treatment in an intensive outpatient psychiatric treatment program • Short-term treatment in a crisis residential program in a licensed psychiatric treatment facility with 24 hour/day monitoring by clinical staff for stabilization of an acute psychiatric crisis • Psychiatric observation for an acute psychiatric crisis

  23. Substance Use Disorder Benefits in the Benchmark Plan • Inpatient Detoxification : Hospitalization for medical management of withdrawal symptoms, including room and board, physician services, drugs, dependency recover services, education and counseling • Outpatient Chemical Dependency Care: • Day treatment programs • Intensive outpatient treatment programs • Individual and group chemical dependency counseling • Medical treatment for withdrawal symptoms • Methadone maintenance treatment for pregnant members during pregnancy and for 2 months after delivery at a licensed treatment center approved by the Medical Group. *Methadone maintenance treatment is NOT covered in any other circumstances • Transitional Residential Recovery Services: Chemical dependency treatment in a nonmedical transitional residential recovery setting approved in writing by the Medical Group that provides counseling and support services in a structured environment.

  24. Parity & The Benchmark Benefits • CMHDA and CADPAAC successfully advocated that language be added to the legislation to clarify that any individual or small group plan or policy issued, amended, or renewed on or after January 1, 2014 must comply with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and all corresponding rules, regulations and guidance. • Inclusion of this reference to federal parity law was particularly important in order to ensure plan/policy compliance with both quantitative and non-quantitative limitations – the latter of which may not be easily discernable in the benchmark EOC. • Some questions still remain regarding coverage of certain substance use disorder treatments, such as methadone maintenance treatment ,which is excluded from coverage in the benchmark EOC.

  25. Behavioral Health Service Plan • As part California’s 1115 Waiver requirements, California must develop and submit to CMS a behavioral health needs assessment and service plan to prepare for the 2014 Medicaid expansion. • The plan is to include the steps and infrastructure necessary to meet requirements of a benchmark plan and ensure strong availability of behavioral health services statewide no later than 2014. The plan will address: • Which benchmark benefit package California will choose • The delivery system(s) for those benefits • Concurrent implementation strategies for financing, enrollment, quality oversight and monitoring, access, and work force development • Recommendations for serving the expansion population • State readiness to meet the MH & SUD needs of this population • California plans to submit a plan to CMS by April 1, 2013.

  26. Los Angeles County Health Reform Readiness:Status of Efforts in Los Angeles County Robin Kay, Ph.D. Chief Deputy Director Los Angeles County Department of Mental Health

  27. Health Reform Readiness:Status of Efforts in Los Angeles County • About Los Angeles County • Very Large County • 10 million residents in over 4,000 square miles • 8 separate Service Planning Areas • Departments of Health, Mental Health, and Public Health (including Substance Abuse) are separate but report to the CEO and are grouped in one “cluster” for planning and oversight • 3 general County hospitals with 4th opening in 2013

  28. Health Reform Readiness:Status of Efforts in Los Angeles County • Los Angeles County Department of Mental Health (LACDMH) • Local mental health plan; operates specialty mental health services to: • 250,000 individuals annually • With $1.89 billion gross Fiscal Year (FY) 2012-13 budget • Network: • 47 directly operated outpatient clinics (108 sites) • 122 legal entity contract providers (388 sites) • Services delivered annually to 35,909 individuals in Los Angeles County jails • 8,857 youth receive mental health services in juvenile justice programs annually

  29. Health Reform Readiness:Status of Efforts in Los Angeles County • Variety of initiatives provide opportunities to prepare: • Migration of SPDs into managed care • 1115 Waiver and the LIHP (Healthy Way L.A.) • Mental Health Services Act • Prevention and Early Intervention • Innovations • Workforce, Education and Training • Board of Supervisors’ Initiatives • Los Angeles County Governance Structure

  30. Health Care Reform Readiness:Coverage Expansion • Objective 1: Ensure Network Capacity (LIHP) • DMH co-locations with DHS • Enhance contracts with 22 legal entities • Develop limited scope contracts with 33 Community Partner agencies and 17 Ryan White providers • FY 2011-12 HWLA/LIHP outpatient services delivered to • 13,192 individuals with serious mental illness • 11,405 individuals with acute mental health disorders

  31. Health Care Reform Readiness:Coverage Expansion • Objective 2: Ensure care coordination through strategic alignment of providers (LIHP) • Objective 3: Ensure timely access through developing and monitoring referral tracking system (SPD; LIHP) • Objective 4: Develop workforce capacity through expansion and development (MHSA WET and PEI) • Objective 5: Implement technology that can enhance care (MHSA; grant) • Objective 6: Develop EHR and HIE (MHSA IT; Los Angeles County Initiative)

  32. Health Care Reform Readiness:System Redesign • Objective 1: Build new structural models • Bidirectional care • Co-location/integration (PEI; LIHP) • Strategic Partnerships (PEI; LIHP) • Integrated community-based teams (BOS) • Integrated Team adaptations for special populations (MHSA Innovations) • Objective 2: Introduce evidence-based mental health treatment strategies • Mental Health Integration Program – University of Washington AIMS Center (MHSA PEI; LIHP) • EBP menu (MHSA PEI)

  33. Health Care Reform Readiness:System Redesign • Objective 3: Ensure effectiveness of new integration models • Outcome evaluation of Project 50 (BOS), Innovations (MHSA), and HWLA (PEI, LIHP) Programs • Objective 4: Ensure integration of substance abuse services • COD assessment and treatment as standard of care • Integration of substance abuse providers in treatment teams/programs • Urgent Care Centers • Project 50 • Innovations

  34. Health Care Reform Readiness:Payment Reform • Challenge of preparing for the unknown • Work with providers, other counties on defining roles/options for public mental health system • An Early Step: California Coordinated Care Initiative (Dual Eligibles Pilot) in a 2-plan county • Use of integrated provider network to avoid discontinuity in care • Joint care management teams determine authorization for payment and level of care • Differing levels of case management intensity • Use of care management algorithms for authorization for service reimbursement

  35. San Mateo County Local Lessons for Behavioral Health on California’s Road to Health Care Reform Louise F. Rogers, MPA Deputy Chief San Mateo County Health System

  36. About San Mateo County • Bay Area Medium size County • Behavioral Health and Recovery Services (BHRS) is part of Health System • Directly operates and contracts for services • Operates specialty mental health plan for Medicaid • Subcontracts to Health Plan of San Mateo to be behavioral health plan for other lines of business • County Organized Health System (COHS) means we have 1 quasi-governmental health plan that covers all Medicaid lives, soon to be most Medi-Medi lives, + other products • Several commercial plans will have a major role with Exchange • Likely Kaiser, Blue Shield

  37. Preparing for Health Care Reform: Coverage Expansion • It has worked in SMC to expand “plan” role of BHRS specialty mental health plan responsible for Medi-Cal to other populations through contracts with Health Plan of San Mateo that delegate management • CareAdvantageMediMedi, Healthworx, Healthy Kids, Healthy Families, psych pharm • Challenge to meet Medicare plan requirements now delegated to BHRS • Expanded plan role of BHRS to manage behavioral health coverage for the Low income health program (LIHP) (early coverage for uninsured adults – Medi-Cal Coverage Expansion (MCE) and Health Care Coverage Initiative (HCCI)) • Local flexibility meant we could implement MH and SUD benefit package modeled on Medi-Cal, medical necessity, levels of care • Required local match • California Medi-Cal SUD very limited so looked to other states • Challenge for counties with public hospitals to integrate SUD claiming in primary health care claim

  38. Preparing for Health Care Reform: Coverage Expansion • It has worked in SMC for BHRS to partner with Health Plan of San Mateo on new duals long term care integration pilot initiative planned for 2013 • Benefits include long term care and other services and supports • Health Plan now focused on how to move people into appropriate community levels of care, investments in housing, appropriate placements for complex co-occurring who are hard to discharge from acute • Challenge to shift health plan model for care management • Effort underway to integrate all the data including MH and SUD for accurate “predictive modeling” and risk assessment, targeting of care management resources • Challenge to address CFR 42 SUD privacy requirements

  39. Preparing for Health Care Reform:Service Delivery Redesign • Lean on the 4 Quadrant Clinical Integration Model and California’s CIMH Integration Policy Initiative papers: http://www.cimh.org/Initiatives/Primary-Care-BH-Integration.aspx • Expanded primary care based mental health and substance use services and consultation throughout system • Challenge with small private primary care providers • Challenge to do SBIRT in primary care and depression screening PHQ 2-9 • Challenge marriage of financing/billing processes (Short Doyle Medi-Cal for specialty mental health, HPSM Medi-Cal, FQHC, Medicare/other, MHSA, etc.)

  40. Preparing for Health Care Reform:Service Delivery Redesign • Expanded specialty mental health clinic based primary care services for SMI adults (nurse practitioners, nurse care managers, peer/health and wellness component) • Challenge meeting space requirements for PCP in MH clinic • Challenge marriage of financial/billing requirements • Challenge shared understanding of eligibility requirements, patient billing • Challenge data integration for care coordination, medication reconciliation, etc. • Planned—leveraging the behavioral health approach with complex-co-occurring for more integrated approach to care management with Health Plan of San Mateo • Hope to improve health outcomes/reduce chronic disease/decrease costs • Previous ED High User efforts never penciled to $ savings to payer that could be reinvested

  41. Preparing for Health Care Reform: Payment Reform • Trying to make the Business Case for Bidirectional Integrated Care to improve health and control total costs through our partnership with HPSM: http://www.cimh.org/Initiatives/Primary-Care-BH-Integration.aspx • SMC BHRS experimented with case rate for Medi-Cal specialty mental health through pilot with State for ten years • Experience was valuable but challenge was it was determined to be untimely/unrealistic for rest of the State • Flexibility was positive but ultimately not what it could be • Siloed--No structural connection to whole health of individual • Provider organizations could not accept risk

  42. Preparing for Health Care Reform: Payment Reform • Delegation agreements with Health Plan of San Mateo currently provide for per member per month fee plus FFS reimbursement for services provided • May push this further in area of care coordination for high risk co-occurring • Will partner with HPSM to hit performance goals under the duals pilot and share in the cost benefit and reinvest

  43. Glenn County The Rural Experience:Glenn County’s Path to Reform Scott Gruendl, MPA Director of Health Services Agency Glenn County

  44. Glenn County Snapshot • Small, Rural, Frontier County with population of 29,000 • Non-Health Plan/Non-Managed Care • One Hospital (semi-public) and 9 Primary Care Providers • No Community-Based Organizations (grow our own) • All Behavioral Health Services provided by county • County Health and Social Service Agencies separate, but have same director and unified executive team • Board of Supervisors has started consolidation of two agencies • Statewide Success: AB109/Transition Age Youth/Employment

  45. Bridge to Health Care Reform: The Bridge Comes in Many Pieces • Bi-Directional Primary Care/Behavioral Health Integration • Implementation of LIHP – Path2Health • Health Information Technology • Service Delivery Redesign • Payment Reform

  46. Bridge to Health Care Reform: Glenn County Health Care Collaborative • SAMHSA PCBHI Grant: • Integrate PCP into Mental Health Clinic (CWRC) • RFP Partnership (FQHC, FQHC Look-Alike, Hospital) • Multi-County FQHC • Lessons Learned: • Facility/Licensing/Scope of Practice issues • Finding the right provider • Staff and Case Ownership • Communication = Daily Debrief and Weekly Meetings • Culture Change • Prescribe Wellness Activities • Unexpected Impacts on SMI (Pain and Anxiety Management, Tobacco) • Create, track, and present outcomes (Progress & Report Cards)

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