Can a person be in both an adult and children's health home with two care managers?
Medicaid for primary care is currently managed care. Behavioral Health is being transitioned and will no longer be carved-out from Medicaid recipient's Managed Care Plans and billed Fee-for-Service.
Please visit https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_reform.htm for more information regarding the VBP Initiative.
Some of the adult clients who are carved-in include those who utilize Personalized Recovery Oriented Services (PROS), mental health / substance use disorder clinics, Assertive Community Treatment (ACT), Home and Community Based Services (HCBS) and opioid treatment programs.
Some of the clients who are carved out include individuals who are 18 - 20 years old and those who participate in Medicaid buy-in, commercial Medicaid or spend down. In addition, dual eligible clients are also carved out.
The transition to a value based system is still in development. Be sure to listen to State and Federal government guidance as well as your managed care plans. Currently, by the 5th and final year of the DSRIP program (2019), all managed care organizations must employ value based payment systems for at least 80-90% of their provider payments.
Additional information provided by the New York State Department of Health can be found here.
Please see the MCTAC Matrix for further information on MCOs in each region.
Small providers should start with where they are and what resources they have. Utilize board members to help with certain tasks or get further financial commitment from the board to help with the process of contracting and preparing for managed care services. In other states, nonprofits have formed affiliations, partnerships or collaborations to use shared infrastructure to help with tracking outcomes, billing, etc.
A recovery-based mental health system embraces the following values: self-determination, empowering relationships based on trust, understanding and respect, meaningful roles in society, and elimination of stigma and discrimination.
The Substance Abuse Mental Health Services Administration, or SAMHSA, offers additional information here.
We recommend that providers use CTACNY.org to be briefed about the transition to managed care. Up-to-date presentations can be found there under Tools and Resources as well as information about all upcoming events. In addition, more specific information about individual services can be obtained through OASAS' FAQs or by directly contacting OASAS and OMH.
An MCO (both mainstream and Health and Recovery Plans, or HARP) is required to offer contracts to behavioral health programs serving 5 or more of its enrollees. Plans may also offer contracts to providers who serve less than 5 of their enrollees. For programs licensed by OMH, the requirement is program specific (i.e., contracts must be offered to all of an agency's mental health clinics, but NOT necessarily its Personalized Recovery Oriented Services (PROS) and Continuing Day Treatment (CDT) programs unless each of them also serve 5 or more of its enrollees). An MCO can contract with all of an agency's MH programs even if one or more of its programs did NOT serve 5 or more of the MCO's enrollees. In addition, an MCO is required to put all of an agency's OASAS programs in its network if that same agency has one or more licenses from OASAS and at least one program serving 5 or more enrollees of that MCO.
Medicare recipients and dual eligible clients are currently carved out of the managed care transition.
LOCADTR is the patient placement criteria system that must be used in making substance use disorder (SUD) level of care decisions in New York State (NYS). LOCADTR assesses the intensity and need of services for an individual with an SUD. All OASAS providers and Medicaid plans will be required to use this tool.
Additional information can be found on OASAS' website.
In New York, the state has imposed an MLR of 89% for its Medicaid Managed Care program. This means that 89 cents of every dollar that flows from the state to the MCOs must be used to pay providers for services and not MCO administrative or marketing costs. If this figure is not met, funds return to the state and a legal process follows. The goal of this standard is to get behavioral health dollars out to providers.