Florida Medicaid Behavioral Health Update

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Florida MedicaidBehavioral Health Update

• SAMH Corporation Quarterly Meeting
• Ft. Lauderdale, FloridaDecember 6, 2006
• Darcy Abbott, AHC Administrator
• Medicaid Services

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Medicaid Reform Is

• Increased access to appropriate care.
• Benefits that better meet recipients needs.
• Access to services not traditionally covered by
  Medicaid.
• An opportunity to provide choice and control to
  recipients in regard to health care decisions.
• Ability to earn credit to pay for non-covered
  services.
• Bridge to private insurance.

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Medicaid Reform is Not

• Reform will NOT change who receives Medicaid.
• Eligibility does NOT change.
• Reform will NOT cut the Medicaid budget. The
  budget will continue to grow each year.
• Reform is NOT connected with Medicare Part D.
• The state will NOT limit medically necessary
  services for pregnant women or children.
• The state has NOT asked to waive Early and
  Periodic Screening Diagnosis and Treatment
  (EPSDT) for children.
• The state will NOT increase cost sharing
  requirements.

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Key Elements of Reform New Options / Choice

• Customized Plans
• 7 of 14 plans waive co-pays
• Plans can offer a range of services, in
  categories such as Home Health and Pharmacy
  Benefits, within boundaries established by the
  Agency.
• Provide New services
• Some plans will offer Over-the-counter (OTC)
  medications adult preventive dental additional
  adult vision respite care home delivered meals
  (post surgical care) circumcisions for newborns.
• Enhanced Benefits
• Earn up to 125 in credits per year by
  participating in healthy behaviors and use
  credits to purchase OTC items at Medicaid
  participating pharmacies.
• Benefits have been established and procedures for
  Plans and the Agency to process EBs developed.
• Beneficiaries are earning credits as of September
  1, 2006.
• Opt-Out to Employer Sponsored Insurance
• The state will pay up to the amount it would have
  paid a Medicaid Plan for the employees share of
  the premium.
• Procedures developed and in place to process
  these payments.

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Key Elements of Reform Financing

• Premium Based
• The use of encounter data and full risk
  adjustment for premium calculation will be phased
  in over the next two to three years to allow the
  state more appropriately to allocate funding to
  the plans.
• Risk-Adjusted Premium
• Distributes capitation payments across health
  plans based on the health risk of the members
  enrolled in each health plan (health status, not
  health use).
• First Risk-Adjusted Premiums have been calculated
  and will be paid starting October 1.

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Key Elements of Reform Delivery System

• Fee-for-Service (FFS) vs. Capitated.
• Coordinated systems of care (HMOs and PSNs).
• Types of managed care organizations participating
  in reform
• Provider Service Network (PSN)
• Fee-for-Service (FFS) PSN.
• Capitated PSN.
• PSNs may form with specialized focus.
• Health Maintenance Organizations (HMO).
• Other licensed insurers.
• Broward - 9 HMOs, 4 PSNs.
• Duval - 3 HMOs, 2 PSNs.

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Choice Counseling Under Reform

• Certified Choice Counselors
• Florida has the only certification program in the
  nation.
• Choice Counseling available
• In Person, Group and Face-to-Face Counseling
  Sessions located near residences of Medicaid
  recipients.
• In the communities.
• Home visits available, if needed by the
  individual.
• Tallahassee Choice Counseling Call Center
  Available 800 a.m. to 700 p.m. Monday-Friday
  and 900 a.m. to 100 p.m. Saturdays.
• Helping Recipients make a choice Provider
  Search. A list of all providers for each plan is
  available to the Choice Counselor
• by Specialist
• by PCP
• Hospital
• Database Updated weekly.
• Beneficiaries may bring advocate to Choice
  Counseling session.
• Choice Counselors inquire whether recipient has a
  doctor who is very important to them.

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Transparency

• Reform relies heavily on measurement of, and
  transparency in, outcomes.
• Transparency among plans is critical in
  empowering consumers.
• Each network will be measured based on consumer
  satisfaction with access to their doctors, and
  other specific performance measures.
• These measures will be public and consumers will
  have access to this information as they choose
  which network to seek care from.
• Base measures set need for expansion is
  apparent.
• Performance Measure public workshops are
  underway.

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Transformation Opportunities and Medicaid Reform

• Integration of mental health and medical services
  under the same plan to promote coordination of
  care.
• The design of Medicaid Reform aligns with a
  transformed system of care
• Enrollee responsibility and empowerment.
• Choice with counseling by trained staff.
• Informed choice of plans.
• Monitoring satisfaction through enrollee surveys.
  
• Mental Health Services
• Plans must provide community mental health
  services as described in the Community Behavioral
  Health Handbook.
• Includes services that support recovery
• Psychosocial rehabilitation services.
• Clubhouse services may be billed
  fee-for-service.
• Plans must provide Targeted Case Management.
• Persons receiving FACT team services will be
  returned to fee-for-service (disenrolled from
  managed care.)

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Transformation Opportunities and Medicaid Reform

• Participating Reform Plans have the flexibility
  to develop a specialized array of services to
  serve a specific group of individuals.
• Plans have incentives to invest in additional
  services not available under fee-for-service that
  will enhance the plans covered services, such as
• Respite care,
• Prevention in the community,
• Parental education programs,
• Drop-in centers,
• In home services for adults.

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Working Together

• Florida Medicaid supports the transformation of
  the Mental Health System and will continue to
  work with DCF to identify and implement
  activities that move transformation forward
• Grants
• Robert Wood Johnson Grant Expand substance
  abuse capacity.
• Adolescent Treatment Grant Developing
  infrastructure for co-occurring substance abuse
  and mental health disorders in teens.
• Policy Development New recovery oriented
  handbook policies
• Mental health.
• Targeted case management.
• Training
• Targeted Case Management.
• Joint training for residential programs in
  reduction of use of seclusion and restraint.
• Participation in Recovery and Resiliency Task
  Force.

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Evaluation of Mental Health Services under Reform

• Comprehensive Evaluation by UF and USF the
  proposed scope of work is currently under
  development.
• Medicaid has requested inclusion of the
  following
• Interviews with adult consumers and caregivers of
  children with serious emotional disturbance.
• Access to services
• Appropriateness of service.
• Consumer engagement.
• Satisfaction, will be refined in subsequent
  evaluations.
• Longitudinal Cohort Study 400 recipients served
  by reform plans compared to PMHP enrollees.
• USF will work with the Florida Peer Network and
  FIFI to identify consumers and family members to
  assist as field surveyors.
• Evaluation of use of psychiatric medication.
• Analysis of mental health service utilization,
  initially from interviews until encounter data is
  available.

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Evaluation of Mental Health Services under Reform

• Medicaid will be working with USF to consider
  inclusion of the Recovery Oriented System
  Indicators (ROSI) in the survey process.
• Additional outcome measures will include
• Days in the community
• Days worked
• Days in school

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Behavioral Health Performance Measures

• Year One
• Number of enrollees admitted to State Mental
  Health Facilities.
• Follow-up after hospitalization for mental
  illness.
• Year Two
• Antidepressant medication management.
• Mental health utilization Inpatient discharges
  and average length of stay.
• Year Three
• Mental health utilization-Inpatient, intermediate
  and ambulatory services

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Behavioral Health Encounter Data for Reform Plans

• HMOs participating in Reform will be the first
  submitters for the 837 Encounter Data.
• Data can begin to be submitted as early as
  January 2007 after testing, certification and
  approval.
• Data will include encounters from September 1,
  2006.
• Medicaid will continue to collect behavioral
  health encounter data in a proprietary format in
  a parallel process until there is confirmed
  reliability with the 837 Encounter Data.

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External Review

• Independent Evaluation by External Quality Review
  Organization as mandated by CMS for all managed
  care plans will evaluate the
• Quality,
• Access, and
• Timeliness of care under Reform.

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Prepaid Mental Health Plan Update

• Area 1- Access Behavioral Health 2001
• Area 2- Magellan Behavioral Health of
  Florida10/06
• Area 3- North Florida Behavioral Health
  Partners10/06
• Area 4- Magellan Behavioral Health of Florida for
  Three Non-Reform Counties (1/07)
• Area 5- Florida Health Partners 8/05
• Area 6- Florida Health Partners 1996 (contract
  extended)
• Area 7 Florida Health Partners 8/05
• Area 8 Florida Health Partners (1/07)
• Area 9 (Magellan Behavioral Health of Florida)
  Unknown due to protest
• Area 10 Reform Area
• Area 11 Magellan Behavioral Health of Florida and
  the Public Health Trust of Dade County 8/06
• CWPMHP Community Based Care Partnership (2/07)

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Behavioral Health Area Advisory Groups

• Area 1 Ongoing quarterly meetings
• Area 2 January 2007
• Area 3 October 2006
• Area 4 TBA for PMHP (Duval September 2007)
• Area 5 Ongoing quarterly meetings
• Area 6 Ongoing quarterly meetings
• Area 7 Ongoing quarterly meetings
• Area 8 TBA
• Area 9 TBA
• Area 10TBA
• Area 11 November 2006

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Medicaid State Plan Process

• The State plan is a comprehensive statement
  submitted by the State agency describing the
  nature and scope of its program and giving
  assurance that it will be administered in
  conformity with the specific requirements
  stipulated in the pertinent title of the Act and
  other applicable official assurances of the
  Department of Health and Human Services.
• State plans are revisions are submitted first to
  the State governor for review and then to the CMS
  regional office for approval.
• The CMS regional office has 90 days to respond.

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Questions