Children’s Service System Transformation in Brief
Conference of Local Mental Hygiene Directors
Monthly Call
NYS OMH Update
December 8, 2015
December 8, 2015
Medicaid Redesign Team’s Vision, Goals and Principles
for Transforming the Delivery of Heath Care for Children
Keep children on their developmental trajectory
Focus on recovery and building resilience
Identify needs early and intervene
Maintain child at home with support and services
Maintain the child in the community in least restrictive settings
Prevent escalation and longer term need for higher end services
Maintain accountability for outcomes and quality
Maintain and expand access to services for children without Medicaid
as a “Household of One”
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December 8, 2015
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The GOAL is to…
Get children back on their developmental trajectory:
•
•
•
•
Identify needs early
Maintain the child at home with support and services
Maintain the child in the community, in least restrictive settings
Prevent longer term need for higher end services
Focus on
recovery and
building
resilience!
December 8, 2015
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Children’s Timeline
Overview
December 8, 2015
Children’s Transition Timeline
• Children will begin to enroll in Health Homes Designated to Serve
Children on September 1, 2016.
• OMH TCM providers and legacy clients will transition on September 1st as well.
• The transition of care coordination services of the five 1915c children’s Waivers (OMH SED,
DOH Care at Home I/II, OCFS Bridges to Health) to Health Home will not occur until 2017.
• The newly proposed health and behavioral health Medicaid State Plan services
will be implemented as soon as possible pending approval from CMS in 2016. The
services will transition to Managed Care in 2017.
Geographic Phase In
• 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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December 8, 2015
Children’s Transition Timelines - continued
• In 2017, currently carved out Medicaid behavioral health services and children in foster care will
be moved to Managed Care
• The existing Home and Community Based Services (HCBS) that are in the five 1915c children’s
Waivers (OMH SED, DOH CAH I/II, OCFS B2H) will be aligned to one array of HCBS benefits,
pending CMS approval, and will be moved to Managed Care. As a result of this transition, the
1915c Waivers will be discontinued as separate programs once the transition is complete.
• Children enrolled in the 1915c Waivers on January 1 and July 1, 2017, will transition to Managed
Care and continue receiving HCBS benefits as per their service plan for 90 days, before service
plan review by the Plans
• In 2017, newly identified children meeting Level of Care criteria may begin to receive HCBS
benefits.
• In 2018, children meeting Level of Need criteria will begin to receive HCBS benefits (January for
children with Medicaid; July for children who meet “family of one” Medicaid)
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December 8, 2015
Enrollment of Children in Health Homes
• Children who have no access to care coordination can access it
• There will be one single model for care coordination of children, integrating physical
and behavioral health
• OMH TCM providers and the children they serve will transition to Health Home in
2016
• HCBS Waiver care managers and the children they serve will transition to Health
Home when the managed care transition occurs in 2017
• Update on the Implementation of Health Homes for Children – Webinar
coming on December 16, 10:00-12:00
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December 8, 2015
OASAS Service Changes
• Clinic to Rehabilitation Designation Change - services where
kids and families are
• LOCADTR-3 - adolescent version
• Residential Redesign - Medicaid reimbursement
• Access to all SPA services
• Health Home access for eligible youth
• HCBS access for eligible youth
• Family/Peer supports
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December 8, 2015
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Looking a Little More Closely Children’s State Plan Amendment
December 8, 2015
Implementation of new Medicaid SPA
Services
• New York will have more Medicaid service options available to intervene earlier
when a child and family experiences behavioral health and other challenges
• Available to all Medicaid eligible children who meet medical necessity criteria
• New York will be able to reimburse Evidence Based Practices through Medicaid
• Unlicensed practitioners, as well as licensed practitioners, will be able to deliver
new services
• Family and youth peers will be able to provide services under Medicaid authority
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December 8, 2015
Current Action Steps - prior to Submission
to CMS
• Rate development
• Finalization of Evidence Based Practice Designation process
• Regulation development
• Finalization of Provider Designation Process
• Finalizing SPA Provider Manual
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December 8, 2015
Proposed New Medicaid State Plan Services
• Crisis Intervention
• Community Psychiatric Supports and Treatment (CPST)
• Other Licensed Practitioner
• Psychosocial Rehabilitation Services
• Family Peer Support Services
• Youth Peer Advocacy and Training
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December 8, 2015
SPA Services Distinction
Chart provided to call participants detailing unique features of each
service along with case examples of how the services might address
individual needs.
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December 8, 2015
Crisis Intervention
• 24/7 availability with one hour response time
• Mobile team-based service in the community where crisis is
occurring
• For a child and his/her family/caregiver who is experiencing a
psychiatric or substance use crisis
• Intended to interrupt and/or ameliorate a crisis experience
including an assessment, immediate crisis resolution and deescalation, development of a safety plan, and referral/follow up to
additional supports
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December 8, 2015
Family Peer Support and Youth Peer Advocacy
and Training
• Services provided by a certified and trained peer with lived
experience
• Family Peer Support Services - array of formal and informal
services and supports provided to families caring for/raising a child
who is experiencing social, emotional, developmental, substance
use and/or behavioral challenges
• Youth Peer Advocacy and Training Services – services that
provide the training and support necessary to ensure engagement
and active participation of the youth in the treatment planning
process and with the ongoing skill development learned
throughout the treatment process
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December 8, 2015
Community Psychiatric Supports and
Treatment (CPST)
• Goal-directed supports and solution-focused interventions
intended to achieve identified goals or objectives as set forth in the
child’s plan of care.
• Face to face intervention, which may include collateral contact
• Delivery in the community by unlicensed practitioner
• Includes the delivery of authorized Evidence Based Practices
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December 8, 2015
Psychosocial Rehabilitation Services
• Implement interventions outlined on a treatment plan to
compensate for or eliminate functional deficits and interpersonal
and/or environmental barriers associated with a child/youth’s
behavioral health needs
• Intent is to restore the fullest possible integration of the individual
as an active and productive member of his or her family,
community and/or culture with the least amount of ongoing
professional intervention
• Delivered by unlicensed practitioner, under clinical supervision
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December 8, 2015
Other Licensed Practitioner
• A licensed behavioral health practitioner, licensed in the State of
New York to prescribe, diagnose and/or treat individuals with
mental illness or substance abuse operating within the scope of
practice defined in State law and in any setting permissible under
State practice law.
• Will include individuals licensed as: Registered Professional
Nurse, Licensed Nurse Practitioner, Licensed Psychologist,
Licensed Social worker (LMSW, LCSW), and Licensed Mental
Health Counselor
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December 8, 2015
SPA Provider Manual
• Service Definitions
• Allowable Activities
• Modality (e.g., face-to-face individual or group)
• Setting
• Admission/Discharge Criteria (i.e., medical necessity)
• Limitations/Exclusions
• Agency/Staff/Supervisor Qualifications
• Training
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December 8, 2015
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What is the 1115 and Why Amend?
December 8, 2016
New York’s 1115 Partnership Plan
• Approved in 1997
• Federal authority to operate a Managed Care Delivery
System
• Amendments required with transition of new populations
or services and/or development of new demonstrations
or services
• Children’s amendment to be submitted to CMS in early
2016
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December 8, 2015
Many changes result from the 1115
• Existing behavioral health services will transition to Medicaid managed care, including
newest six children’s services
• Children in foster care will transition to Medicaid managed care
• The HCBS benefits of the five children’s 1915c Waivers will be aligned into one array of
benefits
• A new expansion eligibility group who meet a Level of Need targeting and functional criteria
will be created
• For children meeting LON and Level of Care and who do not qualify, Medicaid eligibility will
be considered as a household of one without regard to parental income
• For children with Medicaid as a household of one access to HCBS benefits will be paid via
fee-for-service
• The 1915c Waivers will be discontinued when the transition is complete
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December 8, 2015
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Proposed Home and Community Based Services – 2017
• Habilitative Skill Building
• Caregiver/Family Support Services
• Prevocational Services
• Supported Employment Service
• Community Advocacy and Support
• Non-Medical Transportation
• Day Habilitation
• Respite (Crisis & Planned)
• Adaptive and Assistive Equipment
• Accessibility Modifications
• Palliative Care (includes Family Palliative Care Education,
Bereavement, Massage and Expressive Therapy, and Pain and Symptom
Management)
• Care Coordination (for children not eligible for Health Home, CMS
requires care plans for children that receive HCBS services)
 Reflects “alignment” of all HCBS services available under different 1915c
Waiver Programs (OMH SED, OCFS Bridges to Health & DOH Care at Home
I/II)
 Requires CMS Approval of 1115 Amendment for Managed Care
 More tools in the tool box: HCBS available to larger population of children (no
longer limited to waiver slots)
 Broader array of HCBS available, at the same time 1915c Waiver Programs
are discontinued
December 8, 2015
Children’s HCBS Eligibility
To be eligible for HCBS benefits, children must meet:
• target criteria
• functional criteria and
• Medicaid financial eligibility
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December 8, 2015
Children’s HCBS Target Populations
Children and youth younger than 21
• With Serious Emotional Disturbance (SED); or
• Placed in Foster Care who have SED, are Developmentally Disabled or
Medically Fragile, or have experienced abuse, neglect or maltreatment; or
• Who are physically disabled and require significant medical or technological
health supports; or
• With Substance Use Disorders
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December 8, 2015
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Children’s HCBS Functional Criteria
Level of Care (LOC)– criteria met and
determined by assessment that would
indicate a child is eligible for or at risk of
medical institutional placement in a facility
licensed by NYS OMH, Intermediate Care
Facility for the Mentally Retarded (ICF/MR),
or skill nursing facility/Hospital. Current
criteria for children’s 1915(c) Waivers.
NEW Expansion Population: Level of
Need (LON)– criteria met and determined
by assessment that would indicate a child
has needs that cannot be met only by nonmedical institutional State Plan Services, but
who does not qualify for Level of Care.
Both levels determined by CANS-NY (Child and Adolescent
Needs and Strengths Assessment) and its algorithms.
December 8, 2015
One Array of Children’s HCBS Benefits
Managed in two ways:
Medicaid Managed Care AND
Medicaid Fee for Service program
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December 8, 2015
Children with Community Medicaid
• Will be enrolled in Medicaid Managed Care
• Can access Health Home Care Management if they
meet eligibility criteria
• Can access the full array SPA services if they meet
medical necessity for any of the services
• Can access HCBS benefits if they meet targeting and
LOC or LON criteria (determined by completing the
CANS-NY)
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December 8, 2015
Children with Comprehensive TPHI
• Excluded from Managed Care if they are eligible for Medicaid
• Comprehensive TPHI (Third Party Health Insurance) includes those with
commercial coverage, dual Medicaid/Medicare or Medicaid spend down
• Children with Comprehensive TPHI have access to HCBS Waiver Services
today via targeting and functional criteria (LOC) in the 1915c Waivers (OMH
SED, OCFS B2H, DOH CAH I/II)
• Goal to maintain benefit availability to children meeting LOC criteria and
expand to children meeting LON criteria
• If eligible for HCBS benefits, will access through separate but equal system
(Fee for Service) of benefits
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December 8, 2015
Role of the County/City Government in
HCBS Eligibility Determination
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December 8, 2015
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HCBS Eligibility Dilemmas and Proposed
Solution
New York’s goal is to maintain and expand availability of HCBS benefits for
children who need them.
• Problem: Children without Medicaid cannot enroll in a Health Home, which
determines HCBS eligibility
• Problem: A determination of HCBS targeting and functional criteria must be
completed to enable Medicaid financial eligibility determination as a “family of
one”
• Proposal Solution: Development of local Independent Entity function for
“family of one” children
December 8, 2015
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Independent Entity (IE) Functions and Responsibilities
1. Establish a single phone number or physical location for children and families
requesting HCBS benefits
2. The IE will
• conduct a telephonic or in-person Eligibility Evaluation Screen to determine HCBS
presumptive eligibility for those children without Medicaid;
• Enter the Screen question data into the Uniform Assessment System (UAS) on the NYS
DOH Health Commerce System (HCS); and
• Attest to HCBS Presumptive Eligibility Determination based on target and functional criteria.
3. The IE will develop a provisional plan of care, to include the immediate HCBS
benefits that could meet family needs and/or referral to Health Home
4. The IE refers the family to file a Medicaid application with LDSS (HRA) with
verification of HCBS presumptive eligibility.
December 8, 2015
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Independent Entity (IE) Functions and Responsibilities
– (continued)
6. The IE should verify Medicaid eligibility for those children screened until which
time that Medicaid eligibility has been determined.
7. Once Medicaid eligibility is established based on family of one financial
methodology, the IE should inform the family that they are provisionally eligible for
HCBS benefits, the child has been determined Medicaid eligible and ask if they
can be referred to Health Home for care coordination services.
8. If consent is given, the IE enters MAPP via the UAS and completes Health
Home referral and transmits the HCBS Eligibility verification and Provisional Plan
of Care (POC).
December 8, 2015
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Provider Designation
Processes
December 8, 2015
SPA Provider Designation Process
• Must be a licensed, certified or designated provider of OMH, OASAS,
OCFS or DOH within specific parameters
• Process under development, including technical assistance for current
non-Medicaid providers (Family and Youth Peers)
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December 8, 2015
Children’s HCBS Provider Designation
• Grandfathering of current children’s 1915c HCBS
providers
• Expansion of designation for current children’s
HCBS providers
• Application for newly designated children’s HCBS
providers
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December 8, 2015
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“Today and Tomorrow” – Expansion of Services for All Children
Today - 2015
• Current State Plan Services
• Limited Array of HCBS
Services (depending on
Waiver program) available
only to Waiver Children
• Care Coordination Under
1915c Waivers and OMH TCM
Program (12,000)
Tomorrow – 2017 Full
Implementation
• Current State Plan
Services
• Six New Plan Services
(2016)
• Expanded array of HCBS
Services based on LON
and LOC Criteria
• Health Home Care
Coordination – available to
significantly expanded
population of children with
chronic conditions
Questions?
Children’s Managed Care Design
Angela Keller, LMSW
Director, Bureau of Children’s Program Design, Policy &
Planning
Division of Managed Care
NYS Office of Mental Health
Angela.Keller@omh.ny.gov
Children’s Health Home or MAPP
The Health Home Team
Division of Program Development and Management
New York State Department of Health
Office of Health Insurance Programs
(518) 473-5569
HHSC@health.ny.gov
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