Behavioral Heath Solutions
for Medical Health Plans
Mary Ruiz, President/CEO, Manatee Glens
2014 Guide to Behavioral Health Conference
Orlando Florida
Florida’s Medicaid
Managed Medical Assistance
Florida’s General Plans
Managed Medical Assistance
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Amerigroup (Wellpoint)
Better Health (PSN)
Coventry (Aetna)
First Coast Advantage
(PSN Shands)
Humana
Integral (PSN FQHC)
Molina
Florida’s General Plans
Managed Medical Assistance
• Preferred Medical
(HMO)
• Prestige (Blue Cross)
• SFCCN (PSN)
• Simply (HMO)
• Sunshine (Centene)
• United Health
• Staywell (Wellcare)
Florida’s Specialty Plans
Managed Medical Assistance
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Clear Health Alliance HIV/AIDS (Simply)
Freedom Health Duals Chronic (HMO)
Magellan Complete SPMI
Positive Healthcare Florida HIV/AIDS
Sunshine Health Plan Child Welfare
(Centene)
• Children’s Medical Services Chronic (FL
Department of Health)
Florida’s Medicaid
Managed Medical Assistance
Florida’s Medicaid
Managed Medical Assistance
• Community Mental Health
Handbook Benefits
• Targeted Case Management
Handbook Benefits
• Fee for Service Formulary
for One Year
• No PCP Referral for BH
Services—direct access
required
Behavioral
Health Benefits
Florida’s Medicaid
Managed Medical Assistance
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Substance Abuse
Child Welfare Overlay
Comp Assessment
Transportation
Therapeutic Foster Care
Statewide Inpatient
Psychiatric
• Therapeutic Group
Fee for Service
To Managed
Care
Florida’s Medicaid
Managed Medical Assistance
Access
Standards
No Wait List
Urgent One Day
Sick Care One Week
Well Care One Month
MMA Behavioral Health
Coordination Contract Requirements
• State hospital 6 months of last 36 months
• 2 admissions to state hospital in 36 months
• 3 admissions to crisis, SRT or inpatient psych
in 12 months
• Comorbid polypharmacy
• Exceed prescription limits
MMA Behavioral Health
Contract Requirements
• County 24/7 emergency service with RN and on call
behavioral health specialist
• ALF community living support plan and access to
Drop In Centers
• Outreach and care management for non TCM clients
(homeless, ALF, state hospital, jails, juvenile justice)
• Participation in DCF Planning Processes SIPP, State
Hospital
Medicaid Health Plans of America
• Transition Coaches &
Peer Bridgers (Optum)
• Peer Led Warm Line
(Centene)
• Pediatric Residential
Treatment Diversion
(Optum Tennessee)
• Health Risk Assessment
SMI (Centene)
Best Practices
Compendium
Serious Mental
Illness
Provider Challenges
• Lower Rates
• Increased Utilization
Management
• Staff Attrition to Plans
• Increased Admin Costs
• Decreased Cash Flow
• Lower Collection Rates
• Inclusion in Networks
System Challenges
• End of Medical Loss Ratio
for Behavioral Health
• Increased Spend on Medical
Over Behavioral Health
• Increased Spend on BH
Pharmacy over BH Hospital
• Disincentive for Risk Share
• Loss of Transparency on
Total Behavioral Spend and
Practices
• Workforce
New Possibilities?
• Pay for Performance
• Primary Care
Coordination
• Telemedicine
• Substitute Services
• Healthy Behaviors
• Mental Health
Excellence Act
Pay for Performance
System
• Does it improve
outcomes?
• How can outcomes
differ if plan is the
same?
• What are the right
payment models?
Provider
• What is the real
total cost of care?
• Does the data bear
up?
• What innovations
are needed to move
outcomes?
Florida MMA
Contracted Quality Measures
Depression
Strategies
Care, screening, or test
Pharmacy/Lab Reports
Adults newly diagnosed with depression and treated with an
antidepressant who received the following:
Peer Support
Psycho Education
Medication Management
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Effective acute phase: filled sufficient number of Rx to allow for
84 days of continuous therapy.
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Effective continuation phase: filled sufficient number of Rx to
allow for 180 days of continuous therapy.
Care Management
Cognitive Behavioral
To qualify as a new diagnosis, 2 criteria must be met:
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A 120-day (4 month) negative diagnosis history on or before the
start date and a 90-day (3 month) negative medication history on
or before the start date
Florida MMA
Contracted Quality Measures
Mental illness
Strategies
Pharmacy/Lab Reports
Family Education
Medication Management
Care Management
Care, screening, or test
Children 6-12 years who received an initial prescription for
ADHD medication and:
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Received at least one follow-up visit with a prescriber
within 30 days of initiation of medication
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Remained on the medication for at least 210 days and
who, in addition to the visit in the initiation phase, had at
least two more follow-up visits between four weeks and
9 months
Parenting Support
Respite
Florida MMA
Contracted Quality Measures
Alcohol and other drug dependence
Strategies
Care, screening, or test
Intervention
Patients 13 and older diagnosed with alcohol and other drug
dependence who:
Outreach
Harm Reduction
Motivational Enhancement
Peer Support
Medication Assisted
Therapy
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initiate treatment within 14 days of diagnosis
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receive two additional AOD services within 30 days of initiation
Florida MMA
Contracted Quality Measures
Mental illness
Strategies
Care, screening, or test
Care Management
Patients 6 and older discharged from an inpatient mental health
admission and receive:
Respite
Peer Support
Recovery Plan
Family Education
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One follow-up encounter with a mental health provider within
7 days after discharge.
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One follow-up encounter with a mental health provider within
30 days after discharge.
Pay for Performance
MMA
Contract
Penalties
• $10,000 below 50% per
performance group
• Liquidated damages $1.25$3.50 per member
• Failure for face to face with
case manager/bh provider
$5,000 each occurrence
Pay for Performance
Payment Models
Payment Model
Precedence
Enhanced Rate
Mental Health Excellence
Monthly Cap Rate for
Care Management
HMO Primary Care
Monthly Bundled Payment
for Treatment
Florida BNET
Capitation
Prepaid Mental Health
Plans
Pay for Performance
Payment Models
Payment Model
Performance Targets
Enhanced Rate
Access to Care
Monthly Cap Rate for Care
Management
Adherence or High Risk
Monthly Bundled Payment
for Treatment
High Cost
Medical Home
Capitation
Primary Care Coordination
PCP Concerns
• Mandatory assignment of a
PCP required
• 67% of PCP’s say they have
no behavioral health referral
• 30-50% of patients refuse
behavioral health referral
• Psychiatrists don’t interrupt
sessions to take physician
calls
Primary Care Coordination
PCP Adherence Rates
• 20% of patients don’t fill
PCP scripts
• 50% adherence blood
pressure medications
• 20% inhalant compliance
pediatric asthma
• 56% diabetic adherence in
the year following diagnosis
Primary Care Coordination
PCP Outreach
• Build Primary Care Data
Base
• Direct Sales Marketing
• Referral Concierge
• Lunch and Learns
• Tours
• CME/Medical Society Talks
• Troubleshoot Referral
Relationship
Primary Care Coordination
Plan
Demonstration
Projects
• Adherence for asthma,
diabetes, cardiac patients
• Comorbid polypharmacy
• Substance abuse
• All cause readmissions
• High cost
• Medical home features to
PCP practice
• Health risk assessments
for BH caseload
Primary Care Coordination
Plan
Demonstration
Projects
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Body Mass Index
Immunization Status
HbA1c Levels
Blood Pressure
Risk Identification
Functional Outcomes
Medication Compliance
Telemedicine
1.
Community Mental
Health Handbook
2.
MMA Contracts
3.
Provider Contracts
• Allowed for behavioral
health, dental and
physician services
• Hub and spoke
• Telemedicine modifier
code for sixteen services
• Optional not required
• Medicaid prohibition to
pay for equipment
Best Bets for Telemedicine
Enhanced Rate
High Volume
Collaborative Host
• Federally Qualified
Health Center
• Emergency Room
• Department of Health
• Residential Treatment
Center
• Rural Locations
• Children Psychiatry
Florida’s Substitute Services
• Carry forward of the
Prepaid Mental Health Plans
• Not designed for substance
abuse prevention or
treatment services
• Adds medical home
dimensions to care
• Permitted but no plan has
requested use
Substitute Services
1. Plan Request
2. AHCA Approval
3. Provider Contract
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H0038 Peer Services
H2015 Outreach
H006HE Respite
H2019HB In Home
0912 Partial Hospital
T1027 Family Training
H0046HK Therapeutic
In Home
• H2022 Wrap Around
A Florida Strategy for
Substitute Services
• Turn on Substitute
Service Codes
• Redefine to clarify
applications to substance
abuse especially partial
hospital, peer and
outreach
• Add SBIRT at higher rate
• Allow innovations and
flexibility with new
definitions or codes
Healthy Behaviors
Alcohol and Drug Screening and Treatment
• Annual Provider Training
• PCP screening on first visit, routine physicals,
ER utilization patterns
• Provide alcohol or substance abuse recovery
program
• Plan reports on activities to Florida Medicaid
• Residential Detox not a federally covered service
Healthy Behaviors
• Incentive Plans up to $50
Per Enrollee
• Smoking Cessation
• Medically directed weight
loss
• Alcohol or substance abuse
identification
• Identification of Pregnant
Women
Health
Behavior
Services
Healthy Behaviors
• Manage incentive plan
• Sell smoking cessation or
weight loss for current
clients
• Propose alcohol or
substance abuse screening
and engagement service for
PCP
• Outreach to pregnant
women to engage in
prenatal care
Plan
Demonstration
Projects
MMA ADVOVACY INITIATIVES
• Behavioral Health
Medical Loss Ratio
• Code Innovations for
Behavioral Health
• Transparent data, bids,
contracts, reports and
provider manuals
• Mental Health Excellence
Act
• Require that plans include
CMHCs in network
Mental Health Excellence Act
• National Council for
Behavioral Health
Initiative
• Act of Congress on
March 31, 2014
• Improves Medicaid rate
reimbursement 90%
FMAP
• Creates certified
community behavioral
health clinics
Mental Health Excellence Act
• Provides $25m in state
planning grants for 2
year pilot
• Eight states selected to
participate for 2 year
pilot
• Requires states to
develop prospective
payment system
Mental Health Excellence Act
• Publication of clinic
criteria Sept. 1, 2015
• Award of planning
grants Jan. 1, 2016
• Selection of
participating states
Sept. 1, 2017
Mental Health Excellence Act
Clinic Certification
Requirements
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Staffing
Access
Care Coordination
Scope of Services
Quality
Nonprofit/Government
Mental Health Excellence Act
How Florida Gets
Mental Health Excellence
 Florida providers prepare to meet Excellence Act
certification
 Florida legislature authorizes AHCA to apply for
planning grant
 Associations assist AHCA in developing planning
grant application
 Advocate for Florida at Federal Level
 Better align MMA with Excellence Act
 Florida secures planning grant
Don’t Miss This!
Thursday, August 7th 1:30pm-3:00pm workshop
Excellence in Mental
Health Act: Where Do We
Go From Here?
Grand Cypress C
Rebecca Farley
National Council for
Behavioral Healthcare
The Finish Line