NYS Medicaid Managed Care Harm Reduction Services (HRS)

Questions submitted by Health Plans: June 2018

  • Q&As is also available in Portable Document Format (PDF)

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1. Will SDOH provide health plans a list of members currently receiving the services? How many members are currently in treatment in NYS? Will the State provide a list of providers with 5 or more members in treatment to MCO´s?

Harm Reduction is a new service in Medicaid fee–for–service and managed care, there is no data related to prior service delivery. In the past Syringe Exchange Program (SEP) services were limited in nature, grant funded, and client data was anonymous.

2. Are health plans required to complete a plan of care and conduct reassessment every six months?

Harm reduction service providers (SEPs) will conduct initial assessments, reassessments, and create plans of care with tools provided from SDOH AIDS Institute. An enrollee´s plan of care for harm reduction services may be changed every six months or due to an event–driven reassessment.
Reassessment will occur at least once every 12 months.

3. Do Syringe Exchange Providers (SEPs) get licensed or do they get a designation letter?

NYSDOH authorized waivered SEPs receive a designation letter from the AIDS Institute, and are the only organizations eligible to provide harm reduction services.

4. Are there any network requirements, e.g. 2 per county or do we need to contract with all providers in our service area?

Health plans are required to offer a contract to all SEPs who are Medicaid providers in the plan´s service area. The State anticipates a phase in of current grant funded SEP providers into the Medicaid program. 14 of the 23 SEPs across the State have established Medicaid provider numbers for other lines of business, such as a part time clinic, health home care management agencies, laboratory testing, etc. The same Medicaid provider number will also be used for HRS.

5. Would we expect the services to come in with a Behavioral Health diagnosis, HIV or other blood borne disease or it doesn´t really matter?

No. Harm reduction is a low threshold medical service, there are no pre–qualifying conditions or diagnosis code to receive reimbursement. Harm reduction does not fall under the OASAS/OMH requirements that HARPs and Behavioral Health HCBS services require.

6. Will the State mandate credentialing requirements (like HCBS) for these providers or should they go through a full credentialing process?

The SEPs are authorized and waived by the NYSDOH to provide services, which in turn authorizes staff of the SEP to provide the service. A licensed provider is required only to recommend the service.

7. HRS guidance states a recommendation from a "physician or other licensed practitioner" to receive services, does that mean referral is required?

A "referral" as would be used for approval of plan coverage is not required. The requirement language for who recommends the provision of HRS service is broad. The licensed professional recommending the service can be a nurse practitioner; physician; physician assistant; psychiatric nurse practitioner; psychiatrist; psychologist; registered professional nurse; licensed mental health professional; licensed clinical social worker (LCSW); and licensed master social worker (LMSW) if supervised by an LCSW, licensed psychologist, or psychiatrist employed by the agency. The recommending provider can include in house staff. The recommendation for HRS must be in writing and maintained in the enrollee´s patient record.

8. Are all SEPs on the list designated to provide the full range of harm reduction services to enrollees?

Not all SEPs provide the full range of services. For example, service sites such as mobile vans will not be conducive to a group counseling session. However, another SEP may provide group counseling in a larger office based setting.

9. Can the State clarify what will be required in terms of contracting with the SEP providers, including those that do NOT have a Medicaid ID – are plans supposed to set up a single case agreement? Or should plans wait to contract with these providers until each one has a Medicaid ID?

A health plan should wait to contract with providers until a Medicaid ID is established. Plans will receive quarterly updates from the State when this provider expansion occurs.

10. Will the State be looking for any specific reporting related to these services?

At this time, there are no specific reporting requirements.

11. Can more than one of the harm reduction services be provided and reimbursed on the same day?

Yes. As discussed earlier, not every SEP will have the full range of services given staffing and space constraints. For example, client may access a medication management service in a mobile van at one site and attend a group counseling visit at an office site of another SEP later the same day. Additional guidance on UR standards of care is forthcoming.

12. Are there some HRS that would potentially be covered by existing grants managed by the Provider? And, if so how would Providers keep these charges separate?

Yes, SEPs will keep separate records of the provision of grant funded services outside of the Medicaid services, such as the exchange of syringes.

13. What is the mandated timeframe a provider must notify the plan that an existing client is receiving services? Does the plan have the ability to request a concurrent review if the provider fails to notify on time?

Plans may address notification time frames within their contract with the SEP. Concurrent review is not based on lack of notification, and may only be performed at reasonable intervals after the first six months of implementation, when the plan´s criteria has been approved. SDOH will issue further UR guidance.

14 Once a concurrent utilization management process is started, what frequency will the updated Plan of Care (POC) be required to be resubmitted to the plan?

Under section IV of the HRS guidance, it states that "an enrollee´s plan of care for harm reduction services may be changed every six months or due to an event–driven reassessment." Any time a change is made to the POC, or upon reassessment, the POC should be shared with the plan. Reassessment will occur at least once every 12 months.

15. Will SEP providers need to be listed in plan directories/websites?

Yes. The main location of the syringe exchange program will be listed. Additional information on the service site locations can be found on the SDOH website and the provider website.

16. Will plans be monitored on access standards for this? The current provider listing does not cover all counties in NYS – please clarify.

The SEPs anticipated to start Medicaid services delivery on July 1, 2018 cover all regions of the state except Nassau and Suffolk counties on Long Island.

17. The guidance document appears to allow Out of Network (OON) providers to render services. Can SDOH confirm?

Outside of the service area, the plan is required to permit a member to access out of network SEP providers enrolled in the Medicaid program.