Behavioral Health Transition to Managed Care

Overview and Background

As part of Governor Andrew Cuomo´s efforts to "conduct a fundamental restructuring of (the) Medicaid program to achieve measurable improvement in health outcomes, sustainable cost control, and a more efficient administrative structure," the Governor appointed a Medicaid Redesign Team (MRT). The MRT created several work groups to review and provide recommendations in key areas, including behavioral health (BH). The BH work group was co-chaired by Linda Gibbs, the Deputy Mayor of New York City and Michael Hogan, the former Commissioner of the New York State Office of Mental Health (OMH). The 22 members of the work group included Commissioner Arlene González Sánchez of the NYS Office of Alcoholism and Substance Abuse Services (OASAS), advocates, providers, insurers, and other stakeholders from the New York BH community. Through the work group´s six meetings, a series of recommendations were adopted. The MRT adopted recommendations from its BH work group concerning the development of specialty BH managed care.

As a result of the robust public process, the State has submitted an amendment to its current 1115 waiver demonstration to enable qualified Managed Care Organizations (MCOs) throughout the State to comprehensively meet the needs of individuals with BH needs. These needs will be met in the following ways:

  • Mainstream Medicaid Managed Care (MMC) Plans: All adult recipients who are eligible for Medicaid Managed Care (excludes Medicare recipients and certain other populations), will receive the full physical and behavioral health benefit through managed care. Beginning October 1, 2015, plans will cover expanded behavioral health benefits. Also effective October 1, 2015, consumers enrolled in a MMC whose behavioral health benefit was covered under Fee for Service Medicaid through SSI will begin receiving these benefits through the MMC plan.

  • Health and Recovery Plans (HARP) and HIV Special Needs Plans (SNP): Adults enrolled in Medicaid and 21 years or older with select Serious Mental Illness (SMI) and Substance Use Disorder (SUD) diagnoses1 having serious behavioral health issues will be eligible to enroll in a new type of health plan, HARP. These specialty lines of business operated by the MCO will be available statewide. Individuals meeting the HARP eligibility criteria who are already enrolled in an HIV Special Needs Plan may remain enrolled in the current plan and receive the enhanced benefits of a HARP. HARPs and SNPs will arrange for access to a benefit package of Home and Community Based Services (HCBS) for members who are determined eligible. HARPs and SNPs will contract with Health Homes, or other State designated entities, to develop a person-centered care plan and provide care management for all services within the care plan, including the HCBS.

    The State is in the process of designating mainstream MCOs, HARPs, and SNPs to manage the behavioral health benefit in New York City. The State will qualify plans in the rest of the state in the fall of 2015 to ensure that plans meet the requirements for the management of behavioral health services.

  • Children in Mainstream MCOs: Children´s behavioral health services, including all six home and community based service (HCBS) waivers currently operated by OMH, DOH and the Office of Children and Family Services (OCFS), will be included in the Medicaid Managed Care benefit package in 2017.

    The goals of the various managed care models and qualification process are to improve clinical and recovery outcomes for participants with SMI and/or SUDs; reduce the growth in costs through a reduction in unnecessary emergency and inpatient care; and increase network capacity to deliver community-based recovery-oriented services and supports. To ensure Managed Care Organizations are equipped to meet the needs of the behavioral health population, the plans will be reviewed and qualified against new behavioral health specific administrative, performance, and fiscal standards. Implementation will be staggered, according to the timeline described below.

In July 2015, DOH published a Special Edition Medicaid Update on the New York State Behavioral Health Transition to Managed Care.

The September 2015 Medicaid Update contains information for providers regarding HARP Enrollment Notices, billing guidance for behavioral health services, and additional information about pharmacy changes related to the NYC adult behavioral health transition to Medicaid managed care.

Behavioral Health Transition Timeline

Adult Behavioral Health Managed Care Timeline

NYC Implementation

July 2015 - First Phase of HARP Enrollment Letters Distributed (see below for an explanation of initial enrollment process)

  • Enrollment notices will be issued to eligible individuals by NY Medicaid Choice in three phases:
    • Approximately 15,000 issued in July/August for October 1, 2015 enrollment
    • Approximately 25,000 issued in August/September for November 1, 2015 enrollment
    • Approximately 25,000 issued in September/October for December 1, 2015 enrollment

October 1, 2015 Medicaid Managed Care plans and HARPs implement expansion of non-HCBS behavioral health services for enrolled members

October 2015-January 2016 - HARP enrollment phased in

January 1, 2016 - BH HCBS become available for eligible individuals in HARPs and and HIV SNPs

Rest of State Implementation

June 30, 2015 - RFQ distributed (with expedited application for NYC designated plans)

November 2015 - Conditional designation of plans

November 2015-March 2016 - Plan readiness review process

April 1, 2016 - First phase of HARP enrollment notices issued

July 1, 2016 - Madicaid Mainstream Managed Care plans and HARPs implement expansion of non-HCBS behavioral health services and phased HARP enrollment begins

October 1, 2016 – BH HCBS become available for eligible individuals in HARPs and HIV SNPs

Explanation of Initial Enrollment Process

  1. Individuals initially identified by the State as HARP eligible, who are already enrolled in an MCO whose parent company operates a HARP, will be passively enrolled in that plan´s affiliated HARP product after the 30 day opt out period.
  2. Individuals identified for passive enrollment will be contacted by the NYS Enrollment Broker.
  3. They will be given 30 days to opt out or choose to enroll in another HARP.
  4. Once enrolled in a HARP, members will be given 90 days to choose another HARP or return to a mainstream Medicaid managed care plan before they are locked into the HARP for 9 additional months (after which they are free to change plans at any time).
  5. Individuals initially identified as HARP eligible who are already enrolled in a Medicaid managed care plan without an affiliated HARP will not be passively enrolled. They will be notified of their HARP eligibility and referred to the NYS Enrollment Broker to assist with plan selection and enrollment in the plan that is right for them.
  6. HARP eligible individuals in a SNP will be able to receive HCBS services through the SNP. They will also be given the opportunity to enroll in a HARP. They will be notified of their HARP eligibility and referred to the NYS Enrollment Broker to help them decide which Plan is right for them.

Children´s Behavioral Health Managed Care Timeline

July, 2017 - NYC and Long Island Children´s Transition to Managed Care

January, 2018 - Rest of State Children´s Transition to Managed Care

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1 HARP eligibility criteria has been determined by the State. HARP eligibles cannot be dual enrolled (receiving both Medicare and Medicaid) or participating in a program with the Office for People With Development Disabilities (OPWDD)