Children's Health and Behavioral Health Redesign

January 10, 2017

  • Presentation also available in Portable Document Format (PDF)

Agenda

Children´s MRT Redesign – Updates

  • State remains committed to moving forward with Children´s Design
  • Anticipated timeline for implementation of full design runs through January 2019 including VFCA transition in January 2019
  • Depending on timeframes for acquiring necessary approvals (SPAs and 1115 Waiver), the dates may need to be modified accordingly
  • We will continue to move forward with finalizing design documents and as much implementation work as is efficient given uncertain timeframes
  • The submission of the 1115 waiver is pending review of incoming Federal Administration priorities and processes
  • Two SPAs have been submitted to CMS to implement six new SPA services – approval of SPAs and 1115 Waiver continue to be linked, SPAs posted to the DOH Website
  • Children´s SPA and HCBS Provider Designation Application released on December 21, 2016
    • Webinar held yesterday, January 9th
    • Due date to submit applications has been extended to April 1, 2017
    • Title 18 Regulations will be submitted for approvals to formally authorize joint State agency designation process – Designations are contingent upon approval CMS approvals and Title 18 approvals
    • OASAS Part 823 : Children´s Services regulations will be promulgate regulations to establish standards applicable to all providers operated or certified by the NYS Office of Alcoholism and Substance Abuse Services to be designated, or have been designated, to offer EPSDT behavioral health services.
    • OMH Part 511 – OMH will promulgate regulations to establish standards applicable to all providers operated or licensed by the Office of Mental Health that wish to be designated, or have been designated, to offer EPSDT behavioral health services.
  • Draft 1115 document has been finalized, and posted to the DOH Website
    • Stakeholder comments due March 15, 2017
    • Stakeholder webinar, including questions and answers, will be held mid February
  • Draft Plan Requirements and Standards is under final review by State Partners
    • Anticipate releasing no later than the end of month
    • Plan and Stakeholder comments due April 5, 2017
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Health Homes Serving Children Implementation Update

Health Home for Children Launched December 8, 2016!

As of January 8, 2017 – 11,349 children have been engaged by Health Homes

  • ✓ Assignment   4,393
  • ✓ Outreach     3,960
  • ✓ Enrollment   2,996
    •   Assignment: Have been assigned to a HH care manager, but child not yet enrolled or is in outreach
    •   Outreach: Child/legal representative working with a CM – and have not yet signed consent to be enrolled)
    •   Enrollment: Consent has been signed, child is enrolled

Health Homes Designations for Children

The following HHSC were authorized to begin operations on December 8, 2016 – the begin enrollment date for the program.

Adirondack Health Institute, Inc.

Children´s Health Homes of Upstate New York, LLC (CHHUNY)

Collaborative for Children and Families

Coordinated Behavioral Care, Inc. dba Pathways to Wellness Health Home Hudson River HealthCare, Inc. dba Community Health Care Collaborative

Montefiore Medical Center dba Bronx Accountable Healthcare Network Health Home Niagara Falls Memorial Medical Center

St. Mary´s Healthcare

Catholic Charities (Went Live on December 8, 2016 however, not authorized to operate in the following counties: Fulton, Montgomery, Oswego, Schenectady, Schoharie, Schuyler, Seneca, Tioga, Tompkins, Warren, and Washington – Catholic Charities is continuing to work on readiness activities in these counties)

Community Care Management Partners, LLC (CCMP) – (Went Live on December 8, 2016 however, not authorized to operate in the following county of Staten Island, CCMP is continuing to work on readiness activities)

Update on Readiness Activities of Health Homes that Did Not Go Live in December

Central New York Health Home Network (CNYHHN Inc.)
            Readiness Activities Continuing, Plan to "Go–Live" February 1, 2017

Mount Sinai Health Home Serving Children
            Readiness Activities Continuing, Plan to "Go–Live" February 1, 2017

Kaleida Health–Women and Children´s Hospital of Buffalo, DBA Oishei Healthy Kids
            Readiness Activities Continuing, Plan to "Go–Live" February 1, 2017

Greater Rochester Health Home Network LLC
            Readiness Activities Continuing

Institute for Family Health
            Readiness Activities Continuing

Northwell North Shore LIJ Health Home
            Readiness Activities Continuing

Health Home Plus for Children

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Highlevel Overview of Draft 1115 Waiver

Medicaid Redesign Team (MRT) Children´s Redesign

A children´s model of care that enables qualified Managed Care Organizations (MCOs) throughout the State of New York (State) to comprehensively meet the needs of children and youth under 21 years of age.

  • Ensure that the MCO and HCBS benefit packages provided to children are equitable across the State and based on acuity, not dependent upon differences in target population.
  • Ensure that children with co–morbid conditions receive services according to their assessed needs not the system in which they receive care.
  • Provide Home and Community–Based Services (HCBS) for children who are medically fragile, have behavioral health (BH) diagnoses, and who are in Foster Care (FC) with developmental disabilities.

MRT Children´s Redesign

Medicaid Service Changes– SPAs

  • Health Homes for Children Launched December 2016
  • New Addiction Services State Plan Amendment (SPA)
  • New Children´s Services – 2 SPAs
  • Residential Supports and Services (Foster Care, SPA)

Mainstream Medicaid Managed Care 1115 Waiver

  • Including previously exempted and excluded populations
  • Including previously excluded services
  • Regional Phase–in (Downstate, Upstate, Foster Care [FC] Children)
  • SPA services available under 1115 Waiver

Children´s HCBS –1115 Waiver

  • Transition HCBS to demonstration
  • Single HCBS benefit package
  • Health Home care management for HCBS
  • Include new HCBS populations

Draft 1115 MRT Waiver Amendment Summary

  • Incorporate Medicaid State Plan BH services into the managed care benefit package for enrolled children.
  • Provide Children´s HCBS under this 1115 MRT Waiver Amendment:
    • Provide Children´s HCBS through managed care delivery systems on a non–risk basis, for children who are not exempt or excluded from enrollment.
    • Children receiving HCBS and exempt or excluded from managed care will receive services in the Fee–for–Service (FFS) delivery system.
  • Provide Children´s HCBS under this 1115 MRT Waiver Amendment:
    • Transition the five children´s Section 1915(c) HCBS waivers to the 1115 MRT Waiver.
      • Office of Mental Health (OMH) Serious Emotional Disturbance (SED) waiver #NY.0296.
      • Department of Health (DOH) Care At Home (CAH) I/II waiver #NY.4125.
      • Office of Children and Families (OCFS) Bridges to Health (B2H) SED waiver #NY.0469.
      • OCFS B2H Developmental Disability (DD) waiver #NY.0470.
      • OCFS B2H Medically Fragile waiver #NY.0471.
    • Streamline children´s HCBS benefits and administration for consistent eligibility processes and benefits across all populations:
      • Provide Health Home care management for children eligible for HCBS.
      • Offer a single HCBS benefit package for children meeting institutional Level of Care (LOC) criteria.
  • Provide Children´s HCBS under this 1115 MRT Waiver Amendment:
    • Include medically needy children under age 21 with income at or below the monthly income standard or spenddown if they are eligible for HCBS.
    • Continue to include former FC children who were in FC under the responsibility of another state to address a change in CMS policy.
    • Expand HCBS to children at risk of institutionalization meeting Level of Need (LON) criteria but not meeting institutional LOC functional criteria.
    • Expand Medicaid eligibility for children with waived parental income meeting at–risk HCBS LON targeting criteria, risk factors, and functional status to offer an HCBS benefit package identical to the HCBS package for other at–risk LON children under the Demonstration.

Research Goals for Children

The Centers for Medicare & Medicaid Services (CMS) requires states to include evaluation hypotheses to examine the impacts of demonstrations on access, quality of care and costs. An evaluation plan the exact research plan will be developed and submitted to CMS immediately following the amendment approval. New York has included research questions for seven program goals:

  • Goal 1: Improve the health outcomes for eligible HCBS Children and Youth under age 21.
  • Goal 2: Improve timely access to the additional Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits that address early BH needs and health needs of children for improved health outcomes and long term financial savings.
  • Goal 3: Increase access to the uniform HCBS benefit package to improve health outcomes.
  • Goal 4: Increase access to HCBS and reduce the number of children being referred to more costly institutional level of care.
  • Goal 5: Improve access to the integrated Health Home model for all children to improve coordination of care and increase access.
  • Goal 6: Improve the integration of care for children exempted or excluded from managed care in the Demonstration.
  • Goal 7: Improve continuity of care for youth as they transition into the adult Medicaid services system, to the Health and Recovery Plan from the children´s Mainstream managed care benefits.

Draft 1115 Waiver Amendment Summary

  • Timelines included below and in the Draft 1115 Waiver reflect timelines discussed at the November 3, 2016 MRT Meeting and run through January 2019
    • Depending on timeframe for necessary approvals, dates will need to be adjusted accordingly
  • 1115 MRT Waiver Amendment Effective Date – October 1, 2017
    • October 1, 2017 – The five children´s Section 1915(c) HCBS waiver benefit packages and eligibility, and BH services including the new State Plan services transition to the 1115 Demonstration for NYC and Nassau, Suffolk, and Westchester counties.
    • October 1, 2017 – The new populations in NYC and Nassau, Suffolk, and Westchester Counties receive HCBS, and BH services in MMMC or HIV SNP unless otherwise excluded or exempt from managed care enrollment. HCBS children meeting targeting, risk and institutional criteria transition to Health Homes following the regional phase–in schedule.
    • January 1, 2018 – Rest of State implemented.
  • 1115 MRT Waiver Amendment Effective Date – October 1, 2017:
    • July 1, 2018 – Earliest date for children with Medicaid under community eligibility rules meeting at–risk LON HCBS criteria to receive HCBS.
    • January 1, 2019 – Children in VFCAs transition to MMMC and HIV SNPs.
    • January 1, 2019 – Earliest date for children meeting at–risk LON HCBS criteria with family income waived to become Medicaid eligible as "LON Family of One".

1115 MRT Waiver Amendment Eligibility

  • Children eligible for Medicaid under community eligibility rules:
    • Medicaid eligible children who already are in the 1115 MRT Waiver and managed care.
    • Medicaid eligible children who will be enrolled in the 1115 MRT Waiver and receive HCBS in managed care.
    • Medicaid eligible children who will be enrolled in the 1115 MRT Waiver and receive HCBS but are not eligible for managed care.
  • LOC Family of One HCBS Family of One child who meets target criteria, risk factors, and institutional functional eligibility criteria (Eligible today under existing children´s HCBS waivers and will be enrolled in managed care unless exempt or excluded).
  • LON Family of One HCBS Family of One child who meets target criteria, risk factors, and at– risk functional eligibility criteria (New Expansion Population and will be enrolled in managed care unless exempt or excluded).

Children´s HCBS Eligibility

  • To be eligible for Children´s HCBS under the 1115 MRT Waiver, a child must meet targeting criteria, risk factors and functional criteria.
  • There are two levels of HCBS functional criteria:
    • Institutional Level of Care (LOC) – LOC children have an acuity equal to the admission criteria for hospitals, nursing facilities, or ICF–IDD and were historically eligible under the children´s 1915(c) waivers:
    • New Expansion Population: At–risk of institutionalization Level of Need (LON) – LON children have an acuity that places them at–risk of institutionalization but the children do not meet institutional LOC functional criteria.
  • Target Populations meeting institutional admission criteria include:
    • Serious Emotional Disturbance (SED) LOC population.
    • Medically Fragile LOC population.
    • Developmental Disability – Foster Care only – LOC population.
  • Target Populations meeting at–risk functional criteria include:
    • SED LON population.
    • Abuse, Neglect and Maltreatment or Health Home Complex Trauma LON population.

Monitoring Available Resources for LON Expansion Population

  • New York will not maintain waiting lists for children´s HCBS for children who meet institutional LOC.
  • Following mechanisms will be available if the projections of the LON population exceed resources available:
    • If the actual LON enrollment exceeds the projection, the State may modify the non–financial needs–based eligibility criteria.
    • Limit the number of expansion children who are "LON Family of One" at– risk HCBS children to the number of children projected by the New York State Department of Health to be supported by the State´s annual global spending cap.

Children´s HCBS Enrollment CY 2014 & 2022

HCBS Population Children´s actual HCBS Member Months in CY2014 Estimated Children in HCBS CY2014 Proposed annual Children´s HCBS Member Months by 2022 Estimated Children in HCBS by 2022
Medicaid Children meeting LOC under Community Eligibility rules 65,064 6,506 147,869 14,787
Medicaid Children meeting LOC under Family of One rules 12,056 1,206 13,815 1,382
Medicaid Children meeting at– risk HCBS LON under Community Eligibility rules N/A N/A 131,220 13,122
New Medicaid Children meeting at– risk HCBS LON under Family of One rules N/A N/A 36,744 3,674
Total 77,120 7,712 329,648 32,965

Benefit Packages

Eligibility Group Benefit Package
Children not meeting HCBS targeting, risk factors and functional criteria All State Plan and Demonstration services (Outpatient/residential addiction, crisis Intervention, and Licensed Behavioral Health Practitioner (LBHP).
Children meeting HCBS targeting, risk factors, and functional criteria for institutional LOC All State Plan services including Community First Choice Option (CFCO) services — Note: Family of One institutional LOC children will receive CFCO services under the 1115 MRT Waiver, 1115 HCBS children´s services and Demonstration services (Outpatient/residential addiction, crisis intervention, and LBHP).
Children meeting HCBS targeting, risk factors and at– risk LON functional criteria All State Plan services (not eligible for CFCO services), 1115 HCBS children´s and Demonstration services (Outpatient/residential addiction, crisis intervention, and LBHP).

State Plan and Demonstration Services

  • Medicaid State Plan BH Services.
  • Demonstration Services including: Outpatient and Residential Addiction Services; LBHP; Crisis Intervention Services.
  • New EPSDT State Plan services including:
    • Other Licensed Practitioners; Crisis Intervention; Youth Peer Support and Training; Family Peer Support Services; Community Psychiatric Support and Treatment; and Psychosocial Rehabilitation Supports. The following prevention State Plan Amendment will be separately submitted:
      • Residential Supports and Services.
  • CFCO services

Children´s HCBS

  • Health Home
  • Habilitation
  • Caregiver/Family Supports and Services
  • Respite
  • Prevocational Services
  • Supported Employment
  • Community Advocacy and Support
  • Non–Medical Transportation
  • Adaptive and Assistive Equipment
  • Accessibility Modifications
  • Palliative Care
  • HCBS Pilot for Customized Goods and Services including Financial Management Services

Delivery System

Eligibility Group Delivery System
Children not otherwise excluded from Mainstream Medicaid Managed Care (MMMC) or HIV Special Needs Plans (SNPs) including children in direct FC and/or receiving HCBS.
  • Managed care — MCO
  • Health Home Care Management or MCO care management if decline Health Home care management.
Note: HCBS Non–Medical Transportation (NMT) will be provided outside of the MCO by the State´s transportation broker.
Children with HCBS exempted or excluded from MMMC or HIV SNPs. FFS and Health Home care management or care management by State Designated Entity if Health Home care management is declined.

Note: HCBS NMT will be provided by the State´s transportation broker.
  • Children currently in the Demonstration and managed care will not change delivery systems or providers.
  • Children receiving HCBS but not yet eligible for managed care enrollment will remain in FFS until phased into managed care.
  • Children receiving HCBS will be enrolled in and receive care management from the Health Home program.
  • Children that choose not to enroll in Health Home care management and receive HCBS and are enrolled in managed care will receive HCBS care management from the MMMC or HIV SNPs.
  • Children that choose not to enroll in Health Home care management and receive HCBS and are exempted or excluded from MMMC or HIV SNP will receive HCBS care management from a State Designated Entity.
  • Children eligible for HCBS/Medicaid under Family of One will be assessed by a State Designated Entity under a uniform process to determine HCBS/Medicaid eligibility prior to being enrolled in a Health Home.

Customized Goods and Services Pilot

  • No more than eight pilot sites phased in over the demonstration.
  • Funding shall not exceed $2,000 annually per participant.
  • Participation in the Customized Goods and Services pilot is voluntary, and participants may opt–out at any time.
  • The State will develop a waiting list for the pilot, if necessary.
  • Similar to the adult self–direction pilot.

Payment

  • Costs for all 1905(a) State Plan services will be included in the capitated rates.
  • All reimbursement for HCBS covered in the managed care benefit package will be non–risk for 24 months of the Demonstration subject to the non–risk UPL at 42 CFR 447.362. The MCO must pay the fee schedule for non–risk services as long as the HCBS are non–risk (i.e., 24 months).
  • Providers who historically provided care management services under one of the 1915(c) waivers that are eliminated and who will provide services that are being transitioned to Health Home under this 1115 waiver may receive a transitional rate.
  • For essential State Plan services/providers, the MCOs must pay at least the FFS fee schedule for 24 months for:
    • The new EPSDT SPA services including [OLP, Crisis Intervention, Community Psychiatric Support and Treatment, Psychosocial Rehabilitation, Family and Youth Peer Support, and the Preventive Residential Supports],
    • Office of Alcoholism and Substance Abuse Services (OASAS) clinics (Article 32 certified programs),
    • Residential Rehabilitation Services for Youth and
    • Office of Mental Health (OMH) Clinics (Ambulatory Article 31 licensed programs).
    • A fee schedule transition for the Office of Children and Family Services (OCFS) VFCAs for at least 24 months will be developed.

Demonstration Enrollment

  • The current MMMC and HIV SNP enrollment process will be utilized for all children not otherwise excluded and who are eligible for Medicaid under community rules.
  • Modifications to the enrollment process will be made for children eligible for Medicaid under institutional criteria (e.g., the LOC Family of One and the LON Family of One populations) to ensure that the children´s families are given a choice of MCOs during the HCBS Eligibility Evaluation process and Plan of Care process. Specifically, the following process will be followed for Family of One children:
    • The State will select an Independent Entity that will be responsible for various activities relating to children not already enrolled in Medicaid.

MCO Qualification Process

  • Existing MMMC and HIV SNP plans will be utilized.
  • The Department of Health (DOH) will execute a contract amendment to include these new services and populations.
  • An MCO Qualification Standards document will be issued by the State, which will serve as the basis of the contract amendment and a desk review of required components of the children´s transition.
  • The MCO Qualification Standards Document will be circulated for public comment and stakeholder input.
  • The desk review will be followed by in–person readiness reviews, to ensure that the specific requirements of this Qualification Standards document are met prior to implementation and transition.

Budget Neutrality

  • The Centers for Medicare and Medicaid Services (CMS) requires amendments to cost the federal government no more than the cost without the Demonstration.
  • Populations and services coverable today such as HCBS to current Medicaid populations and the LOC Family of One children do not require the State to document savings for the Federal Government to match those costs.
  • CMS has the discretion to provide federal match for coverage of additional individuals. New populations such as LON Family of One children require the State to document sufficient federal Medicaid savings to cover the cost of the federal financing of the expansion population.

Public Notice

  • The MRT BH Work Group began meeting on June 30, 2011 in New York City and the subcommittee for children´s BH was subsequently formed. Since 2014, the Children´s MRT Health and BH Subcommittee has met quarterly. Meeting dates and materials can be found here
  • DOH, OASAS, OCFS and OMH continue to regularly meet with Managed Care Plans, Provider Associations, parents and constituents regarding this important BH Transition from FFS to Medicaid Managed Care.
  • Public notice of the proposed amendment occurred on September 21, 2016 for 30 days. This amendment incorporates changes and suggestions by the public from that process.

Children´s OLP and Rehab SPA Link

  • The Children´s OLP and Rehab SPAs can be found here

Stakeholder Feedback on Children´s 1115 Waiver Amendment

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RESOURCES TO STAY INFORMED:

OMH Managed Care Mail Log

Subscribe to Children´s Managed Care Listserv

Subscribe to DOH Health Home Listserv

Health Home Bureau Mail Log (BML)

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