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 MCOs: All adult recipients with mental illness and/or substance use disorders who are eligible for Medicaid Managed Care (excludes Medicare recipients and certain other populations), will receive their full medical and behavioral health benefit through managed care. Individuals with serious behavioral health issues will be eligible to enroll in Health and Recovery Plans (HARPs), as described below. Those who are not eligible for HARPs, or who choose not to enroll in a HARP, will be enrolled in a Mainstream Plan for their medical and behavioral health benefit.

  • Health and Recovery Plans (HARPs) & HIV Special Needs Plans (HIV SNPs): Adults enrolled in Medicaid and 21 years or older with select SMI and SUD diagnoses1 will be eligible to enroll in HARPs. These specialty lines of business within the mainstream MCO will be available statewide. Individuals who meet the HARP eligibility criteria who are already enrolled in HIV Special Needs Plans (HIV-SNPs) may remain in their current plan and still receive the enhanced benefits of a HARP plan. HARPs and HIV-SNPs will arrange for access to a benefit package of Home and Community Based Services (HCBS) for their members who are determined eligible. HARPs and HIV 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 HIV 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 mainstream MCOs 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 MCOs 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.

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)

  • NY Medicaid Choice enrollment letters will be distributed in three phases:
    • Approximately 20,000 July/August distribution for October enrollment
    • Approximately 20,000 August/September distribution for November enrollment
    • Approximately 20,000 September/October distribution for December enrollment

October 1, 2015 - Mainstream Plans and HARPs implement non-HCBS behavioral health services for enrolled members

October 2015-January 2016 - HARP enrollment phases in

January 1, 2016 - HCBS begin for HARP population

Rest of State Implementation

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

October 2015 - Conditional designation of Plans

October 2015-March 2016 - Plan Readiness Review Process

April 1, 2016 - First Phase of HARP Enrollment Letters Distributed

July 1, 2016 - Mainstream Plan Behavioral Health Management and Phased HARP Enrollment Begins

Explanation of Initial Enrollment Process

  1. Individuals initially identified by NYS as HARP eligible, who are already enrolled in an MCO with a HARP, will be passively enrolled in that Plan's HARP.
  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 Mainstream 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 an MCO without a HARP will not be passively enrolled. 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.
  6. HARP eligible individuals in an HIV SNP will be able to receive HCBS services through the HIV SNP. They will also be given the opportunity to enroll in another 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

January 1, 2017 - NYC and Long Island Children´s Transition to Managed Care

July 1, 2017 - 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)