Washington State Health Reform

1. Washington State Health Reform Quarterly Meeting Northwest Portland Area Indian Health Board January 20, 2015

2. Agenda • Integrated Purchasing of Medicaid Physical and Behavioral Health Care • Background • Coming Changes • Planning Calendar • Possible System Models • Possible Service Models • Other Questions • Comments – January 5, 2014 • Accountable Communities of Health • Background • Comments – January 5, 2014 • Governor’s Health Innovation Leadership Network • Seeking recommendations for Tribal Representative and Urban Indian Organization Representative

3. Integrated Purchasing of Medicaid Physical and Behavioral Health Care Background

4. Apple Health (Medicaid) Managed Care • Since early 1990s, Medicaid transitioning beneficiaries to health planswith CMS approval • Today, over 90% of full-benefit Medicaid eligiblescovered through Apple Health Managed Care Plans • State pays PMPM (per-member, per-month) to Plans with defined set of benefits for defined groups —each Plan is fully “at risk”* for care of assigned population • Currently, Apple Health Managed Care Plans cover physical health care services and mental health care services below the access to care standard *”at risk” means that the MCO is paid a per member per month (PMPM) rate to provide the full array of services they are under contract for. If the MCO spends more than it receives from HCA, the MCO loses money. If the MCO spends less than it receives, the MCO can keep a portion of this money. CMS requires the PMPM to be an actuarial rate and HCA to monitor and incentivize MCOs to ensure appropriate care is provided to clients.

5. Managed Care Today: Not Integrated State contracts with entities to provide Medicaid services by county MCO = Medicaid Managed Care Organization RSN = Regional Support Network Other Medicaid services (such as chemical dependency treatment and dental services) are provided outside of managed care (on a fee-for-service basis)

6. Legislative Directives (Senate Bill 6312) Purchasing Reforms Clinical Integration Primary care services available in mental health and chemical dependency treatment settings and vice versa Access to recovery support services Opportunity for dually-licensed CD professionals to provide services outside CD-licensed facility • Regional purchasing - DSHS & HCA jointly establish common regional service areas for behavioral health and medical care purchasing • County authorities elect fully integrated purchasing (Early Adopter RSAs)by April 2016, with opportunity for shared savings incentive payment (up to 10% of state savings in region) • Other RSAs – separate managed care contracts for physical health (MCOs) and integrated behavioral health care (newly created Behavioral Health Organizations)

7. Goals: Integrated Purchasing of Managed Care • Provide more holistic, better managed carefor people with co-occurring disorders. • Support seamless access to serviceswith standards and medical necessity guidelines in one system, without “access to care” standard. • Improve ability to monitor quality across all providers • Quality metrics in managed care contracts • Sanctions for specific performance measures. • Align financial incentivesfor expanded prevention and treatment and improved outcomes across physical and behavioral health systems. • Create system for interdisciplinary care teamsthat are accountable for full range of physical and behavioral health services. • Improve information and administrative data sharing, making relevant information more available to multidisciplinary care team.

8. Integrated Purchasing of Medicaid Physical and Behavioral Health Care Coming Changes

9. Parallel Paths to Integrated Purchasing 2014 Legislative Action: 2SSB 6312 By January 1, 2020, the community behavioral health program must be fully integrated in a managed care health system that provides mental health services, chemical dependency services, and medical care services to Medicaid clients 2020: Full Integration of Behavioral Health and Medical Care Across the State Transition Period Apple Health Managed Care Plans Fully Integrated Purchasing in “Early Adopter” RSAs, with shared savings incentives Behavioral Health Organizations 2016 Regional Service Areas (RSAs)

10. Medicaid Managed Care Purchasing in 2016 State will contract with entities to provide Medicaid services by RSA *There will be no “access to care” standard in Early Adopter RSAs “Access to care” standard is a threshold for intensity of mental health services that are needed for a client. BHO = Behavioral Health Organization FFS = Fee-For-Service (not managed care) MCO = Medicaid Managed Care Organization RSA = Regional Service Area RSN = Regional Support Network

11. Regional Service Area Designations By April 1, 2016, HCA and DSHS will regionalize purchasing of health care services.

12. North Central RSA in Transition Transitional two-RSA approach for counties presently served by the Chelan-Douglas and Spokane RSNs: • Apple Health Managed Care:New North Central RSA separate from Spokane RSA • BHO:Single BHO will serve new North Central and Spokane RSAs during the transition • 2020 Full Integration: Fully integrated managed care is required in 2020 by Senate Bill 6312. North Central and Spokane RSAs will be separate regions for purposes of integrated physical and behavioral health managed care systems in 2020.

13. Special Cases − Potential Early Adopter RSAs Counties in 3 RSAs have expressed interest in early adoption of fully integrated physical and behavioral health care purchasing in 2016. Non-binding letters of intent are due in January 2015.

14. Medicaid Purchasing in “Early Adopter” RSAs • Standards being developed jointly by HCA and DSHS • County authorities in an RSA must agree to become Early Adopter RSAs • Procurement processwill be necessary to select MCOs • Compliance with Medicaid and State managed care contracting requirements • Shared savings incentives • Payments to Early Adopter counties targeted at 10% of savings realized by the State, based on outcome and performance measures • Available for up to 6 years or until fully integrated purchasing occurs statewide • Models continue to be discussed broadly

15. Some Criteria for MCO Early Adopter Participation Managed care organizations must: • Meet network adequacy standards established by HCA and pass readiness review • Provide full continuum of comprehensive services, including critical provider categories (e.g., primary care, pharmacy, and behavioral health) • Ensure no disruption to ongoing treatment regimens • Be licensed as an insurance carrier by the Office of the Insurance Commissioner • Meet quality, grievance and utilization management and care coordination standards and achieve NCQA accreditation by December 2015

16. Currently Proposed Roles

17. Integrated Purchasing of Medicaid Physical and Behavioral Health Care PLANNING CALENDAR

18. Medicaid Integration Timeline 2015 2014 2016 Early Adopter Regions MAR Full integ. RFP Draft managed care contracts/ Preliminary Rates OCT-DECRegional data; purchasing input NOVFinal managed care contracts JAN-MAR Full integ. Draft contract MCO/Stakeholder Feedback JANSigned contracts AUGVendors selected JUNMCO Responses Due JULModel Vetting JUNPrelim. models Common Elements MARCMS approval complete MAY-AUGSubmit 2016 federal authority requests Provider network review P1 correspondence DEC- JANFederal authority approval; Readiness review begins NOVDSHS/HCA RSAs Joint purchasing policy development SEPFinal Task Force RSAs JUL Prelim. County RSAs MARSB 6312; HB 2572 enacted APR Integrated coverage begins in RSAs BHO/ AH Regions NOV JANAH BHO contract detailed signed plans reviewed Revised AH MC contract APRFinal BHO and rev. AH contracts OCTBHO detailed plan response AH network due JUL BHO detailed plan requirements Draft BHO managed care contracts 2016 AH MCOs confirmed AH RFN (network) MAR-MAY Development of draft contracts and detailed plan DEC-FEB Review and alignment of WACs for behavioral health OCT-DECBHO Stakeholder work on rates; benefit planning for behavioral health RSA – Regional service areas MCO – Managed Care Organization BHO – Behavioral Health Organization AH – Apple Health (medical managed care) SPA – Medicaid State Plan amendment CMS – Centers for Medicare and Medicaid Services Early Adopter Regions: Fully integrated purchasingBHO/AH Regions: Separate managed care arrangements for physical and behavioral health care November 4, 2014 Key Opportunities for Tribal Feedback and Consultation

19. HCA Calendar for Early Adopter Planning & Implementation Tribal consultation/ comments on: Draft MCO Contract, Early Adopter Model Options, and Criteria for MCO vendor selection (part of RFP process).

20. Integrated Purchasing of Medicaid Physical and Behavioral Health Care POSSIBLE SYSTEM MODELS

21. Potential BHO RSA Model: Physical & Behavioral Health Purchasing with Separate Managed Care Arrangements State DRAFT Collaboration Counties Accountable Communities of Health • Business • Community/Faith-Based Organizations • Consumers • Criminal Justice • Education • Health Care Providers • Housing • Jails • Local Governments • Long-Term Supports & Services • Managed Care Organizations • Philanthropic Organizations • Public Health • Transportation • Tribes • Etc. Behavioral Health Organizations • Mental health (Access to Care Standard (ACS)) • Substance use disorders Apple Health Managed Care Plans • Physical health • Mental health (non-ACS) DRAFT Carved-Out Services & Tribal Programs Physical Health, & limited Mental Health (non-ACS) providers Mental Health & Chemical Dependency Providers Individual Client

22. Potential Early Adopter RSA Model: Fully Integrated Physical & Behavioral Health Purchasing with Standard Managed Care Arrangements Early Adopter Agreement State Counties in RSA DRAFT Collaboration Accountable Communities of Health • Business • Community/Faith-Based Organizations • Consumers • Criminal Justice • Education • Health Care Providers • Housing • Jails • Local Governments • Long-Term Supports & Services • Managed Care Organizations • Philanthropic Organizations • Public Health • Transportation • Tribes • Etc. Licensed Risk-Bearing Managed Care Plans DRAFT Carved-Out Services & Tribal Health Programs Physical Health, Mental Health and Chemical Dependency Providers Individual Client

23. Potential Early Adopter RSA Model : Fully Integrated Physical & Behavioral Health Purchasing with Single Shared Regional Behavioral Health Network Early Adopter Agreement State Counties in RSA DRAFT Collaboration Accountable Communities of Health • Business • Community/Faith-Based Organizations • Consumers • Criminal Justice • Education • Health Care Providers • Housing • Jails • Local Governments • Long-Term Supports & Services • Managed Care Organizations • Philanthropic Organizations • Public Health • Transportation • Tribes • Etc. Licensed Risk-Bearing Managed Care Organizations DRAFT Single shared regional network of essential behavioral health providers Carved-Out Services & Tribal Programs Physical Health, Mental Health and Chemical Dependency Providers Individual Client

24. Integrated Purchasing of Medicaid Physical and Behavioral Health Care POSSIBLE SERVICE MODELS

25. Current Medicaid + Non-Medicaid Service Administration

26. Medicaid-Funded Services – Early Adopter RSAs & Behavioral Health Questions: There may be transition period for MCOs to build in-house behavioral health expertise. HCA is considering allowing subcontracting of certain essential behavioral health functions (but not financial risk) for 18 months. Are the proposed “essential behavioral health functions” the right functions to allow subcontracting for? Is 18 months the right timeframe? Are there other limits on subcontracting to consider? “Essential Behavioral Health Functions” would include utilization management, network development, provider relations, quality management, data management and reporting. *In Early Adopter RSAs, there may not be a county-based entity responsible for mental health or chemical dependency treatment.

27. Medicaid-Funded Services – Early Adopter RSAs & AI/AN Clients Questions: How can HCA facilitate better care for Medicaid clients who opt out of Managed Care? What can HCA do to keep AI/ANs in Managed Care?? How can HCA best support Tribal clinics? Would Tribal clinics consider becoming in-network providers? How can HCA facilitate better care coordination between BHOs and MCOs across RSAs? *In Early Adopter RSAs, there may not be a county-based entity responsible for mental health or chemical dependency treatment.

28. State/Local-Funded Services – Early Adopter RSAs & Non-Medicaid Funds • Question: • Who should administer these funds and services? • Each MCO administers portion of non-Medicaid funds • Single MCO or Administrative Service Organization (ASO) administers all non-Medicaid funds in coordination with MCOs • Split design • Each MCO administers funds for Medicaid clients • Single MCO or ASO administers funds for non-Medicaid clients

29. State/Local-Funded Services – Early Adopter RSAs & State Hospital Beds Question: How will state hospital beds be allocated and how will MCOs reimburse the State if the hospital bed allocation in their region is exceeded?

30. State/Local-Funded Services – Early Adopter RSAs & Crisis Services • Question: • Should the State contract with an ASO on a regional basis for the provision of crisis services? Are there other models that make more sense? • Model 1 – ASO holds non-Medicaid contract and bills MCOs for Medicaid-allowable services • Model 2 - ASO holds Medicaid and non-Medicaid contract with the State • Which “crisis services” should be part of the regional crisis system managed by the ASO? What should go into the contract for the MCOs (E&T services)? • If MCOs are not at financial risk for their clients’ use of the crisis system (Model 2), how do we ensure that MCOs use the crisis system appropriately?

31. Early Adopter RSAs & Crisis Services – Model 1 DRAFT DRAFT State Contract for Non-Medicaid Crisis Services Non-Medicaid Contract Non-Medicaid Contract Medicaid Contract Medicaid Contract Regional Crisis System Managed by ASO Medicaid Managed Care Organization Medicaid billing Medicaid billing Medicaid Managed Care Organizations Required sub-contract Required sub-contract • Data reporting • Examples of Behavioral health including: • E&T providers • DMHPs/CDPs – 24/7 • Crisis hot line • Crisis stabilization Continuum of Integrated Clinical Services Individual Client

32. Early Adopter RSAs & Crisis Services – Model 2 DRAFT DRAFT State Non-Medicaid Crisis Contract PMPM for Medicaid Crisis Non-Medicaid Contract Non-Medicaid Contract Medicaid Contract Medicaid Contract Regional Crisis System Managed by ASO Medicaid Managed Care Organization (Penalties when members access crisis) Required Coordination Required Coordination Medicaid Managed Care Organizations (Penalties when members access crisis) • Data reporting • Examples of Behavioral health including: • E&T providers • DMHPs/CDPs – 24/7 • Crisis hot line • Crisis stabilization Continuum of Integrated Clinical Services Individual Client

33. Potential Crisis System Models: Descriptions Model 1 Model 2 Single regional behavioral health crisis system, managed by an Administrative Service Organization (ASO), subcontracts with an established regional behavioral health crisis provider system, for the delivery of Medicaid and non-Medicaid crisis services to Medicaid and non-Medicaid individuals on a cost-reimbursement basis. ASO holds a contract with the State for all non-Medicaid services, provided to both Medicaid and non-Medicaid enrollees. The ASO also receives a PMPM for all Medicaid crisis services provided to Medicaid enrollees. The cost for Medicaid crisis services is not included in the PMPM for Medicaid managed care organizations (MCOs). MCOs are required, in contract, to coordinate with the crisis system and are penalized when their members access the crisis systemor held at performance risk for their members use of crisis services. • Single regional behavioral health crisis system, managed by an Administrative Service Organization, (ASO) subcontracts with an established regional behavioral health crisis provider system, for the delivery of Medicaid and non-Medicaid crisis services to Medicaid and non-Medicaid individuals on a cost-reimbursement basis. • The ASO holds a contract with the State for all non-Medicaid services, provided to both Medicaid and non-Medicaid enrollees. • MCOs in the region are required to subcontract with the ASO for the provision of Medicaid/non-Medicaid crisis services to their enrollees. In this model, the ASO would bill the MCO for Medicaid-allowable services provided to their enrollees, which would be included in the MCO’s Medicaid PMPM. • The ASO’s contract with the State would fund the non-Medicaid services provided to the Medicaid enrollees and non-Medicaid individuals. The State-ASO contract would also include funding (as in the case of RSNs today) for the ASO to reimburse the county for court costs.

34. Integrated Purchasing of Medicaid Physical and Behavioral Health Care OTHER QUESTIONS

35. Behavioral Health Provider Network What behavioral health provider types should be included in the Essential Community Provider Network? • CMHAs, state-owned and operated hospitals, crisis providers, inpatient and outpatient SUD providers • Opioid treatment programs • Mobile crisis, crisis residential, respite beds

36. Model of Care • Draft Model of Care available for review • Draft Model of Care will be background for procurement • Questions: • What needs to be strengthened? • Is any section overly prescriptive? • Has anything been left out? • Does the framework (4 quadrant adaptation) help with understanding of program goals?

37. Integrated Purchasing of Medicaid Physical and Behavioral Health Care COMMENTS - january 5

38. Medicaid Integrated Purchasing – Thoughts/Concerns from January 5, 2015

39. Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015

40. Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015

41. Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015

42. Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015

43. Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015

44. Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015

45. Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015

46. Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015

47. Accountable Communities of Health Background

48. Healthier Washington • Improving how we pay for services…so people and their providers can choose the best treatment options • Ensuring health care focuses on the whole person…people’s physical and mental health care are integrated to better meet their needs • Building healthier communities through a regional approach…local organizations work together to build strategies that work for their community

49. Healthier Washington Strategies include: • Accountable Communities of Health to support locally-driven goals, approaches, and processes • Redesign of provider payments*to improve the quality and value of care • Creation of a regional extension serviceto share information about best practices *Tribes are not participating in provider payment redesign effort.

50. Accountable Communities of Health Clinical Community What is an Accountable Community of Health (ACH)? • A group of public and private organizations and individuals working together to integrate health care and improve health in their region • Participants include: public health, housing, and social service providers; MCOs; insurers; county and local government; Tribes; and consumers ACHs