Utah’s Pre-paid, Capitated
Behavioral Health Medicaid Plan
NACBHDD Legislative Conference,
Washington, D.C.
March 4, 2013
Kyle Snow, ED, Northeastern Counseling Center, kyles@nccutah.org
Mike Deal, ED, Southwest Behavioral Health, mdeal@sbhcutah.org
Pat Fleming, DD, SLCo Div. Behavioral Health Services, pfleming@slco.org
Community
Mental Health
Movement Took
Firm Hold
State Level
Reorganization
“Genesis”
1980’s-90
Followed by the
Expansion of Grant
Funding for Community
SUD Svc’s and Svc’s For
Older Americans
Child Welfare
Disability
Services
STATE
Juvenile Justice
Services
Child Welfare
Disability Services
Juvenile Justice Services
Counties
Human
Services
Aging
Services
MH &
SUD
Services
Utah began adding optional services to it’s Medicaid plan, including MH Svc’s to the
disabled populations…inpatient psychiatric services were covered…
Overbuild of
psychiatric
facilities - costs
skyrocket
Counties given
responsibility to
manage optional
Medicaid Program
& inpatient costs
1993
Cost savings to be
used to expand MH
Svcs (Medicaid &
Unfunded/uninsured)
Utah’s Capitated
MH Plan was born
- with almost full
coverage across 13
Co MH Authorities
by 1996
1996 – 2004 Worked exactly as designed, inpatient costs under control, allowed counties to expand while
decreasing demand on State funds. It worked too well. 2006 – CMS changes, savings to be used for Medicaid only.
Three Common
Financing Methods
1. Cost reimbursement model
2. Fee-for-service model
3. Capitated model
Capitation Model – What is it?
• Under this model, payer or providers, receive a
fee for each enrollee to cover a specified level of
behavioral health care and offer a defined
package of services, for a specified period of
time. The enrollees are usually residents of a
specific area. Enrollee may be identified from a
specific list. Payer or provider assumes risk (all
risk, shares risk, limit risk share, etc.), associated
with delivering services to enrollees.
When to use Capitation
Model
• When behavioral health expenditures growing faster
than available funding.
• When acute behavioral costs (inpatient care) growing
more rapidly than the outpatient or traditional
behavioral health expenditures.
• When available funding is being reduced or no growth
in funding is being projected within the near future.
• When coordination of benefits of patient between
different providers is not being done or very limited.
• When provider network is providing unnecessary
services or keeping patients in higher levels of care
longer than needed.
How Do You Determine Enrollee Rates
• Need to know total units of service provided by service
code.
• Need to know Medicaid units of service provided by
service code.
• Need to know cost by service code.
• Need to know Medicaid units of service by service
code and by rate cell.
• Need to know Third Party Liability or insurance
collection by Medicaid rate cell.
• Need to know the number of eligibles by rate cell or
category.
How Many Eligible or Rate Cells to Use?
State of Utah has
over 130 eligibility
categories.
Each
based up a set of
criteria submitted to
CMS (Centers for
Medicare
and
Medicaid Services).
Too many to use!!!!!
Utah has chosen to
collapse all these
into 10 categories.
State of Utah’s 10 Eligibility
Categories
1. AFDC 0 to Age 5 Years
2. AFDC 6 to 18 Years
3. AFDC 19 to 64 Years
4. Aged (65 Years and Older)
5. Disabled Male (All Ages)
6. Disabled Female (All Ages)
7. Pregnant Woman (All Ages)
8. Medically Needy Child (0 to 18
Years)
9. Medically Need Adults (19 to 64
Years)
10.Foster Care
Example of Monthly Payment Capitation
•
Utah uses a prepaid full capitation prepaid model. Under this model, the govt.
agency, MCO, Providers and etc. receives a fixed amount of money for providing
services to a patient for a particular period of time, including all the cost
associated with behavioral health. (Inpatient hospital, outpatient, supported
living, and other services - pharmacy is not included.) Prepayment allows agency
a chance to contract for all services, staff for services and etc., without having to
acquire large loans, or restrict prior years earning, to cover cost of providing the
service.
ROW TITLES
Pay
Date
BIRTH
THROUGH
6 THROUGH
18 YEARS
NONTRADITIONAL
DISABLED
MALE
DISABLED
FEMALE
ADULTS
(ALL AGES)
(ALL AGES)
5 YEARS
Current Month Eligibles First
Rates for Year
Amount of First Check
New Eligibles for Month
Rates for Year
Amount of Second Check
New Eligibles for Month
Rates for Year
Amount of Third Check
New Eligibles for Month
Rates for Year
Amount of Fourth Check
New Eligibles for Month
October 1, 2012
$
$
October 8, 2012
$
$
October 15, 2012
$
$
October 22, 2012
$
$
October 22, 2012
325
12.83
4,169.56
40
12.83
513.18
22
12.83
282.25
10
12.83
128.29
3
$
$
$
$
$
$
$
$
700
13.04
9,129.19
80
13.04
1,043.34
10
13.04
130.42
6
13.04
78.25
4
$
$
$
$
$
$
$
$
490
25.22
12,359.07
30
25.22
756.68
15
25.22
378.34
11
25.22
277.45
4
$
$
82
193.37
15,856.64
16
193.37
3,093.98
14
193.37
2,707.23
11
193.37
2,127.11
10
95
$
190.85
$ 18,131.20
16
$
190.85
$ 3,053.68
15
$
190.85
$ 2,862.82
15
$
190.85
$ 2,862.82
5
59,645.68
182
$
8,460.85
76
$
6,361.06
53
$
5,473.93
26
$
3,079.56
$ 25,718.70 $ 27,864.80 $
83,021.06
$
$
$
$
$
$
$
12.83
$
13.04
$
25.22
$
193.37
$
190.85
Amount of Fifth Check
$
38.49
$
52.17
$
100.89
$
1,933.74
$
954.27
Total for Month
$
5,131.77
$ 13,872.43
1,692
$
Rates for Year
$ 10,433.36
TOTALS
Advantages of Capitation
• Strong incentives to minimize financial costs.
• Strong incentive to intervene earlier in patient’s
treatment rather that waiting until clients admit
at inpatient hospital.
• Strong incentive to coordinate patient’s care
between programs and providers.
• Patient is likely to receive only those services
and interventions that are necessary.
• Limits the chances of exceeding the budget that
has been approved.
• Encourages the use of new programs that limit
the exposure to the more intensive services
such as inpatient.
Disadvantages of Capitation
• Agencies, providers, MCOs, and etc., (providers) have an
incentive to limit the quantity of services provided to the
patient.
• Patients may potentially receive less than optimal care since
both quality and quantity may increase costs.
• In capitation-based settings, it is not as easy and
straightforward for the patient to change her therapist.
• Providers may limit the days in intensive care to less than
optimal before releasing back to the community to reduce
cost, thus placing family, the new provider and the patient at
greater risk.
• Agency overseeing capitation contract may incur additional
costs for monitoring to ensure appropriate levels and quality
of care are provided to the patients.
So which of the three methods is the best, cost
reimbursement, fee-for-service, or capitation?
• At Salt Lake County we use all three methods. Each has as
mentioned advantages and disadvantages.
• We use the cost reimbursement for new programs and programs
looking for a particular usually non traditional service. (24 Crisis line)
• We use fee-for-service with our substance abuse providers with a
ceiling on the max dollars allowed per year. The monthly amount is
limited to allow for services throughout the year.
• On our mental health services both inpatient and outpatient we have
placed our MCO contractor at full risk with reimbursement based
upon the enrollment of eligibles in the 10 categories mentioned. But
we added an additional aspect with our MCO any unspent funding
will be deposit into an account maintained by our MCO, but
belonging to Salt Lake County. These funds have been used to open
new programs and cover shortfall in the falling year.