Are adult Home and Community Based Services (HCBS) only made available for HARP eligible clients?
Yes, HCBS services are only available to clients that are enrolled in a HARP or an HIV SNP after they've undergone assessment and the assessment has indicated that they are eligible and for which services. For more information consult a recent workflow presentation.
Will Managed Care Organizations know who the designated adult Home and Community Based Services (HCBS) providers are? How do providers find out who the adult HCBS providers are?
Yes, Plans are provided this information and when available the list of the adult designated providers is also publicly available on the OMH website, and can be accessed here.
How do associations, agencies, and non-Medicaid providers get designated to provide adult Home and Community Based Services?
All agencies wishing to provide BH HCBS must apply to be designated for each service they would like to provide. Applicants may apply at any time for a designation; however the state will only update the designation lists quarterly for each area on a periodic basis.
Can homeless clients use the Crisis Respite Home and Community Based Service for adults?
If an individual is HARP eligible, yes, but note that Crisis Respite has usage caps outlined in the HCBS manual and MCTAC trainings.
How do agencies identify if an adult client is HARP/HCBS eligible?
HARP/HCBS eligiblity information is available using ePaces.
Are HARPs required to have case managers? How are clients assigned to Health Home Care Managers?
Yes, HARPs are required to have case managers. The expectation is that most face to face care management will be done through the Health Homes. Each Health Home has its own assignment process.
How do adult BH Home and Community Based Services (HCBS) work for those between the ages of 18 and 21?
The adult BH HCBS services are only available to eligible adults ages 21 and over in HARPs or HIV SNPs.
Is there a cap for how many family members or collaterals the person may identify to receive adult Family Support Services?
No. The individual receiving this service is the one who decides which family members and other collaterals may be engaged in the service.
What trips are covered under adult Home and Community Based Services non-medical transportation?
Please refer to MCTAC's non-medical transporation webinar, held on January 9, 2017, which provided guidance on allowable vs. non-allowable trips. Resources from this webinar can be found here.
Can a recipient of adult Home and Community Based Services (HCBS) also receive Health Home Care Coordination without duplication of services?
Yes. All clients receiving adult HCBS are eligible for Health Home Care Coordination.
What are the requirements and expectations regarding supervision of peer support specialists/advocates for adults?
Per state issued guidance, supervision of peer support must be provided by a licensed behavioral health practitioner. The frequency of supervision should be determined as clinically appropriate.
How do adult BH HCBS providers access the manual for ePaces codes?
Providers can access the ePaces manual by clicking on ePaces help. Codes start on page 259.
Will there be any standards concerning choice and conflict of interest (for the service choices the clients are making)?
The federal government is very serious about conflict free choice in HCBS. Providers will need to document the choices being offered to the client and the state will collect and monitor that information.
Are HCBS certification and provider qualifications, requirements or guidelines? Do all criteria need to be met? Can staff waivers be obtained and if so how?
New York State HCBS certification and provider qualifications are requirements. All criteria must be met and at this time there are no staff waivers.
For adult BH HCBS clients, what are tiers 1 and 2?
Client tier status is determined by the brief Community Mental Health Assessment. Tier 1 indicates eligibility for select HCBS services including Employment, Education and Peer Supports. Tier 2 indicates eligibility for the full array of HCBS. The brief assessment may also find that an individual is not eligible for HCBS. All HARP enrolled individuals are eligible for short-term crisis respite.
For adult BH HCBS clients, under what circumstances does the Plan of Care need to be redone?
The plan of care should be redone if the tier of eligiblity, services and/or goals have changed or may no longer be appropriate based on observation or a major life change. Contact your Health Home Care Manager for more information.
What is HARP?
According to the NY Department of Health, "Adults enrolled in Medicaid and 21 years or older with select Serious Mental Illness (SMI) and Substance Use Disorder (SUD) diagnoses having serious behavioral health issues will be eligible to enroll in a new type of health plan, HARP. These specialty lines of business operated by the MCO will be available statewide. Individuals meeting the HARP eligibility criteria who are already enrolled in an HIV Special Needs Plan may remain enrolled in the current plan and receive the enhanced benefits of a HARP. HARPs and SNPs will arrange for access to a benefit package of Home and Community Based Services (HCBS) for members who are determined eligible. HARPs and SNPs will contract with Health Homes, or other State designated entities, to develop a person-centered care plan and provide care management for all services within the care plan, including the HCBS."
How do providers determine who has been designated part of a HARP?
Individual HARP eligibility and enrollment are included in ePaces. Information regarding Managed Care Plans that participate in HARP is available at the MCTAC Plan Matrix.
How many individuals are enrolled in a HARP?
New York State has identified approximately 120,000 individuals throughout NYS.
Who will determine if an adult is HARP eligible?
New York State determines who is HARP eligible. Individuals are eligible if they meet target risk criteria/risk factors or are identified by the service system or a service provider.
Target Criteria: -Eligible for mainstream enrollment and Medicaid enrolled, -21 and older, -Serious Mental Illness/Substance Use Disorder diagnosis, -Not dually eligible for Medicare, -Not participating in OPWDD program
Are adults in HIV SNPs included in HARPS?
Individuals in HIV SNPs are eligible for all services associated with HARP/HCBS under same rules as HARP eligible individuals.
How will managed care plans work with legal mandates (parole supervision, etc.)?
New York State expects managed care plans and providers to continue to follow any legal/court mandated aspects of treatment.
How does confidentiality factor in, when you have calls from Medicaid and managed care organizations needing client information?
If a provider does not have a contract (or is in the middle of contracting) with a managed care plan, how does that provider pay the plan for individual clients?
The provider will have to communicate with the managed care plan to determine how to handle this client. Usually a single case agreement will be reached.
Will the specifics of outlier management be shared?
A specific list of outliers will likely not be generated because context is key to determining an outlier. For more guidance around outlier management consult the October 2015 OMH and OASAS UM Implementation presentations, available via the links below.
Are providers required to provide care before authorization from the managed care plan?
Typically no, a provider is not required to provide care before the managed care plan gives authorization. Exceptions include if there is a crisis situation or an organization's own policies and procedures require them to provide care.
Is prior-authorization required for adult clients?
This varies by program and service type. Please refer to MCTAC's guidance on utilization management on our website's resources page, found here.
What are some strategies for providers to use to figure out their costs?
Work with your CFO or budget team to calculate your staffing, administrative and unit of service costs. For a sample model, utilize the CTAC benchmarking tool.
If someone is denied due to medical necessity or if managed care is refusing to pay, is there an appeals process?
Yes. The first step in the appeals process would be to initiate a discussion with the managed care company. If this is unsuccessful, a formal appeals process can then be instituted. Managed care has created external and internal appeals processes. It's important to recognize that the formal appeals process can be lengthy and time-consuming.
Contact information for a specific plan's appeals department can be found on the MCO matrix at matrix.ctacny.org.
What should providers do when clean claims differ across payers?
If a provider were to use a certified peer from an existing program, would it affect the staffing plan of that program, e.g. a peer from a PROS program providing an adult Behavioral Health Home and Community Based Service (BH HCBS). Will peer time for the BH HCBS be subtracted from PROS staffing plan?
Yes. Sharing staff between your adult BH HCBS and other certified programs is allowed; however, the total time (FTE) that an employee spends on BH HCBS must be separated out on the CFR, and the PROS staffing plan must account for this.
What is the timeframe for adult Behavioral Health Home and Community Based Service (BH HCBS) providers to complete the assessment(s) for frequency, duration, and scope of each individual service?
The initial assessment by the adult BH HCBS provider to determine frequency, duration, and scope must be completed within 14 calendar days from the first visit.
Will each adult Behavioral Health Home and Community Based Service (BH HCBS) provider receive a copy of the individual’s Plan of Care? Will the BH HCBS Individual Service Plans be shared among providers?
The BH HCBS plan of care is completed by the Health Home Care Manager. Once complete, the BH HCBS plan of care must be signed by each of the BH HCBS designated agencies providing a BH HCBS service indicated in the HCBS plan of care.
For adult CPST what are the criteria for a “licensed professional,” and does a CASAC (Credentialed Alcoholism and Substance Abuse Counselor) meet these criteria?
CPST must be provided by "Professional Staff",” as defined in the BH HCBS Manual appendix. The manual qualifies that those licenses are issued via NYSED and are focused on the provision of direct services related to the treatment of mental illnesses and SUDs. The CASAC credential is a certificate issued by OASAS, and as such should not be included.
For adults, how is CPST different from outpatient clinic or ACT (Assertive Community Treatment)?
CPST is a Behavioral Health Home and Community Based Service (BH HCBS) available to individuals who are identified as having that need via the NYS Community Mental Health Assessment. It is a stand-alone service providing clinical mental health services to individuals in the community, at the intensity that best meets the individual’s needs. As opposed to outpatient clinic, CPST must be provided off-site, in the individual’s home or a community setting.
ACT is an evidence-based treatment approach targeting people who are resistant to traditional methods of
service delivery or for whom those approaches have not proven effective. There are specific treatment modalities employed, specific staff competencies and trainings proscribed; these are provided by closely monitored consistent teams specializing in a variety of disciplines and life areas, with a focus on ongoing monitoring and communication between all members via their daily Team Meeting. There is no provision in BH HCBS, or specifically CPST, for this intensity of service. The foundation of BH HCBS is that they are consumer-driven and recovery-oriented; they are not intended to address the intense engagement needs that ACT-appropriate consumers have.
Individuals receiving ACT services are not eligible for BH HCBS while they are receiving ACT services.
Can an adult OASAS-Certified Peer provide services to a mental health client and vice-versa?
OMH and OASAS certification programs are separate. The best practice would be for a peer specialist to have the certifications that aligns with the population with which he or she is working. For those working with the dually-diagnosed population, it is recommended that they have both certifications to be fully prepared to serve that population.
Can adult Behavioral Health Home and Community Based Services (BH HCBS) be provided in group settings?
The only BH HCBS that may be provided in groups are Psychosocial Rehabilitation Services and Family Support & Training services. All other BH HCBS must be provided 1:1.
Often times adult peer support specialists provide support through phone, email, and texting. Can these activities be billed under adult Behavioral Health Home and Community Based Services (BH HCBS) Peer Support?
NYS recognizes that peer support specialists provide many valuable activities beyond face-to-face interventions. However, all BH HCBS must be provided face-to-face. Phone, e-mail, and texting would not be considered billable activities.
How will adult HCBS services fit into a community with a PROS (Personalized Recovery Oriented Services) program? When would a client be appropriate for Home and Community Based Services (HCBS) versus PROS?
When choosing when, where, and how to receive services, individuals should be provided with the opportunity to make an informed choice. PROS is a comprehensive and integrated service model that is able to support multiple goals. BH HCBS may be appropriate for individuals who want to work in the community on 1-2 goals, who are averse to attending a program, or who require 1:1 services that a PROS program cannot sustain. The individual, together with his or her Health Home Care Manager and Managed Care Organization (MCO), will determine whether PROS or BH HCBS are more appropriate to help him or her attain or maintain his or her goals. Additionally, there are certain BH HCBS (such as Peer Support and Education Support Services) that can be provided to an individual who is enrolled in PROS.
Who will be responsible for determining if an adult assessed as eligible for Behavioral Health Home and Community Based Services (BH HCBS) lives in a Home and Community Based setting?
This should be determined by the Health Home Care Manager. Further guidance on the HCBS settings requirements is forthcoming.
Can individuals who reside in OMH-licensed Community Residences receive adult Home and Community Based Services (HCBS) in off-site locations?
Community Residences are non-compliant settings for BH HCBS. Individuals residing in community residences are ineligible to receive BH HCBS.
Can Behavioral Health Home and Community Based Services (BH HCBS) be provided in individuals’ homes?
The state encourages BH HCBS providers to provide services in the individuals’ homes and in community locations. Determinations regarding where services will be provided should be made in partnership with the individual. It should be noted that services cannot be provided in residential settings that are not HCBS compliant (such as psychiatric centers or community residences), and individuals who reside in these settings are not eligible to receive BH HCBS.
How will determinations be made regarding settings that are subject to Heightened Scrutiny? Are individuals who reside in Scattered-Site housing considered eligible to receive adult Home and Community Based Services (HCBS)?
The housing settings that currently qualify as HCBS settings include an individual’s own apartment, scattered-site Supported Housing units, or in a family home. BH HCBS designated providers are expected to sign and submit to OMH an BH HCBS Settings Attestation form, declaring site compliance with the BH HCBS settings rule. Therefore, it is the responsibility of the providers to ensure standards are met. Settings under Heightened Scrutiny will not be approved until organizations have submitted a Heightened Scrutiny Self-Survey. Additional details on the survey will be provided. Further guidance regarding HCBS settings compliance is forthcoming.
What are the requirements for Education Specialists for adult HCBS?
All Education Support Staff should have a minimum of two years working in behavioral health. Education Specialists should possess a Bachelor's degree and have two years of experience supporting individuals in pursuing education goals. A supervisor may be unlicensed and requires a minimum of a Bachelor's degree (preferably a Masters in Rehabilitation or a relevant field), a minimum of three years of relevant work experience, preferably as an education specialist.
If an individual has previously failed in an education program, is he or she eligible to receive adult Education Support Services? Is there a minimum number of credits or classes an individual needs to pursue?
If the individual has been assessed as eligible for BH HCBS Education Support Services, has a goal that requires the service, and wants to receive the service, it should be included in the Plan of Care. Failing to complete an educational program in the past does not preclude an individual from receiving this service in the future. There is no minimum number of courses or classes in which an individual must be enrolled. Ongoing Supported Education is provided when an individual has been admitted to an educational or training program.
If an individual is eligible for ACCES-VR, how can adult Behavioral Health Home and Community Based Services (BH HCBS) provide employment and education services?
The BH HCBS Provider Manual stipulates that Education and Employment services may be provided to the extent to which they are not available under a program funded by the IDEA or available for funding by ACCES-VR. BH HCBS services and ACCES-VR services can complement each other, and whenever appropriate, the Health Home Care Manager and provider should ensure coordination with the ACCES-VR Vocational Counselor. It is important that an individual be provided the opportunity to make an informed choice between services and providers. Further guidance is forthcoming.
Are adults who are actively using substances, who have a history of substance use, or who have a history of incarceration eligible for education or employment services?
If the individual has been assessed as eligible for Behavioral Health Home and Community Based Services (BH HCBS), has a goal that requires the service, and wants to receive the service(s), it should be included in the Plan of Care. Substance use and a history of incarceration should not be used an exclusionary criteria for these services.
What would be the typical sequence(s) through which an adult would move between the various services in the Employment cluster?
Behavioral Health Home and Community Based Services (BH HCBS) Employment and Education services are not meant to be sequential. An individualized and person-centered approach should be used to identify the service(s) that are most appropriate to meet the individual’s needs.
Are adult Intensive Supported Employment and Ongoing Supported Employment subject to the same 250-hour cap that includes Pre-vocational Services and Transitional Employment Services?
Pre-Vocational Services and Transitional Employment are capped together at 250 hours per year. Intensive Supported Employment and Ongoing Supported Employment are each capped individually at 250 hours per year. An assessment by the provider will determine the appropriate frequency, scope, and duration of services. The provider(s) must work with the Plan and the Health Home Care Manager to ensure appropriate utilization management. In addition to the caps on the number of hours, providers should be aware that there are utilization thresholds listed in the Billing Manual that also apply.
Can adult CPST services and PSR services be provided concurrently, and if so, how will two different providers ensure that the combined 500-hour cap is not exceeded?
CPST and PSR may be provided concurrently. It will be important for providers to maintain contact with the Plan and Health Home Care Manager to ensure appropriate utilization management. Following an assessment, each provider will make recommendations regarding scope, duration, and frequency of the service. All BH HCBS are subject to utilization thresholds.
How are adult Psychosocial Rehabilitation (PSR) and adult Habilitation different?
The adult BH HCBS Provider Manual provides definitions of each service. PSR services are designed to assist the individual with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their behavioral health disorder. Habilitation services are designed to assist individuals in acquiring, retaining, and improving skills necessary to reside successfully in home and community-based settings.
Should Health Homes assess only HARP-enrolled individuals, or are we expected to assess all HARP-eligible individuals for Behavioral Health Home and Community Based Services (BH HCBS) eligibility?
Where can families go to access Adult Home and Community Based (HCBS) Family Support Services?
In order for an individual (and their family) to access this service, they must go through an assessment process conducted by the Health Home Care Manager. Based on the results of the assessment, the Care Manager will work with the individual to determine which BH HCBS will be received. Even if an individual is eligible to receive this service, his or her family members may only be involved at the individual’s request.
What are the training and experience requirements for adult Family Support staff? Is there a credentialing process?
There is no certification or credentialing process specific to providers of Family Support and Training. This service may be provided by unlicensed staff who have at least a high school diploma or equivalent and 1-3 years of relevant experience working with individuals with behavioral health disorders. OMH-certified Peer Specialists and OASAS-certified Peer Advocates, CASACs, CASAC-T’s, and Certified Psychiatric Rehabilitation Practitioners (CPRPs) may also provide this service.
For adults, can Family Support & Training be offered to the individual alone to review and assess the plan, or does a family member need to be present in order to bill?
Family Support and Training is provided to family members at the individual's request. In order to bill for this service, a family member must be present.
Can you explain the group ratios for adult BH HCBS? The fees matrix has rates for groups of 2 or 3, but the HCBS Provider Manual indicates that you can have up to 16 individuals in a group.
Family Support and Training groups are limited to 2 or 3 families at a time, with no more than 16 individuals in any one group.
When will an updated Adult Behavioral Health Home and Community Based Services (BH HCBS) Provider Manual be available?
For the initial 3 assessment visits with an adult individual how will the Behavioral Health Home and Community Based Services (BH HCBS) provider bill for these services? Will these visits have a different rate than the service rate? Will these visits apply to the utilization cap?
BH HCBS providers have up to 3 visits to determine the scope, duration, and frequency for the individual based on their needs, goals and preferences. This is a part of the BH HCBS and should be billed the same way an individual BH HCBS is billed. The time spent during these three visits will count toward the cap on hours.
Can adults who are homeless receive Home and Community Based Services (HCBS)? Does it make a difference if the individual is sheltered or unsheltered?
OMH and OASAS will release further guidance on providing services to individuals who are homeless.
Regarding UM, who organizationally is best situated to handle/manage?
There isn't one path fits all -- depends on an organization's size, how many clients, and how many contracts with MCOs. A recommended approach is to balance centralized vs individual. Consider how well equipped a central staff, social worker or nurse is able to speak to a case just by looking at a chart? On the other side, training 20 people to do UM reduces the amount of time they can spend on other things. Also raises question of supervision.
Can a person be in both an adult and children's health home with two care managers?
This whole redesign is based on the premise that things are very inefficient. How did NYS compare so poorly to the rest of the country? What are we supposed to be improving on?
NYS is ranked very low among US states in terms of the cost of healthcare and quality outcomes. This coupled with our extremely high rate of inpatient admissions has prompted a statewide change for healthcare management and utilization. The issue is not with individual providers and agencies but with the larger system. Also, compared to other states, New York has added more services under its Medicaid program which has driven costs higher without the greater level of coordination.
Is Medicaid a managed care system already?
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.
Will agencies that have applied to be designated HCBS services for both adult and children, be rejected?
On the OMH website, the adult HCBS with NYC and rest of state designation information is public. There is also contact information if you have questions about or wish to change your designation. Look on the OMH site or under "Tools and Resources" on mctac.org for the appropriate links.
If an agency provides services to both children and adults and has been approved for adult BH HCBS, do they receive automatic approval for the children's HCBS?
No, the designation process to provide HCBS services to children is a separate and distinct process from the Adult HCBS designation.
What consideration will there be for complexity and comorbidity in the capitation formula?
Complexity of co-occurring and chronic conditions for children are being taken into account when determining rates and program design.
How will the Value Based Payment system work?
There is information on the Department of Health's website regarding DSRIP and the VBP initiative. Visit http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/
Is a Plan of Care required if the only BH HCBS the adult is receiving is Non-Medical Transportation (NMT)? What is an example of an appropriate NMT trip for an individual who is not receiving any other BH HCBS?
NMT is considered a BH HCBS, and therefore the HCBS requirements for Plans of Care must be met when NMT is utilized. However, the State does not expect that there will be many individuals for whom it will be appropriate to use NMT and not be engaged in other BH HCBS. An example of an appropriate NMT trip for an individual who is not receiving other BH HCBS is a trip to a job interview for an individual with an employment goal who is engaged in a Personalized Recovery Oriented Services (PROS) program and therefore is not eligible for the BH HCBS employment services.
Where is the adult Non-Medical Transportation (NMT) Grid accessed?
Do adult BH HCBS providers bill for Non-Medical Transportation (NMT)?
BH HCBS providers would only provide and bill NMT if they are enrolled Medicaid transportation providers and are assigned transportation by the manager. Transportation is assigned via enrollee choice within the appropriate level of service or rotation when no choice is expressed. When billing for NMT, enrolled Medicaid transportation providers must receive prior authorization from the transportation manager and bill through eMedNY through the same billing process as fee-for-service Non-Emergency Medical Transportation (NEMT).
Can adult BH HCBS providers bill for mileage for staff trips related to an individual’s goal?
Non-Medical Transportation (NMT) is a BH HCBS and is separate from Staff Transportation which is a supplemental rate add-on for some BH HCBS. BH HCBS providers can bill for mileage for staff trips, as long as the mileage is tied to a service that was provided and it is a service that qualifies for Staff Transportation. The services that qualify are essentially all services, except NMT, respite services, and Psychosocial Rehabilitation or Family Support and Training if those services are provided to a group. Information about Staff Transportation is also available in the billing manual here.
What is the timeframe in which the MCO must confirm the proposed Non-Medical Transportation (NMT) is appropriate based on the approved POC/Level of Service Determination decision and send the Grid to the Transportation Manager?
If the NMT Grid is received with the level of service determination request, the MCO should forward the Grid to the Transportation Manager at the time of the approval of the level of service. If the Grid is received after the Level of Service approval, the MCO should review and make a decision regarding the appropriateness of the proposed NMT within the timeframe for Service Authorization Requests in Appendix F of the Medicaid Managed Care/Family Health Plus/HIV SNP Model Contract.
Where on ePaces can providers find the adult HCBS codes?
On ePaces, providers should be looking at the section that lists the restriction and exception codes. Providers are looking for the "H codes."
What are the engagement expectations (e.g. missed appointments)?
Providers should look closely at program specific requirements and contracts with managed care organizations for engagement expectations.
Who's included, or carved-in, and who's excluded, or carved out?
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.
Managed care organizations have to pay state rates for two years. How much freedom/flexibility is there from regulations for alternative payment rates?
Plans have flexibility. State agencies have indicated that they are interested and open to alternatives but approval will be needed.
Are Personalized Recovery Oriented Services (PROS) clients, dual eligible clients, etc. designated as Fee-for-Service (FFS) or managed care?
PROS clients are included in, or carved-in to, Medicaid managed care.
Dual eligible clients are now excluded, or carved out, from Medicaid managed care but have an option for managed Medicare. Dual eligible clients who are not in Fully Integrated Dual Advantage (FIDA) programs will remain in FFS. Agencies should not dismantle FFS as clients are still enrolled in it (e.g. non-FIDA dual eligible clients).
How will providers transition from the Fee-For-Service(FFS) system to the value based system?
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.
Is there a list of Managed Care Organizations (MCOs) in each region?
Please see the MCTAC Matrix for further information on MCOs in each region.
How receptive are plans to the negotiation of contracts?
The managed care organization is going to start with its own template agreement for the type of service but contracts are negotiable. For example term and termination are definitely negotiable, assignment can be negotiable. On the other hand compliance with laws is not going to be negotiable. If planning to negotiate a lot of the provisions providers may want to consult with a lawyer. But often plans do not use lawyers in favor of provider contract teams. During negotiation, focus on things that are important from a business perspective. Remember some, like "performance standards," may not be in the main contract; they may be in appendices.
Can providers bill retroactively (i.e., "back bill")?
Plan eligibility is not retroactive. Accordingly, bill Managed Care Organizations (MCOs) fee-for-service (FFS) for 2-3 months. Refer to the guidance found in this presentation.
How will the State measure outcome based performance versus the volume of services provided? Who sets and who measures these goals/outcomes and over what time period?
The State is working on developing social/recovery outcomes to evaluate the quality of services provided.
With multiple payers and multiple contracts how can small organizations survive and even thrive?
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.
If managed care organizations are not mandated by NYS to contract with providers, will plans still give other providers contracts?
Plans may offer contracts to providers other than those they are mandated to offer contracts to. Please refer to slide 15 of "Contracting and Credentialing."
Are clinicians mandated to code their own sessions?
Yes, clinicians are mandated to code their own sessions.
What is the definition of "recovery-based"?
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.
After the mandatory enrollment period ends, what can be done to prevent managed care organizations from contracting with one agency and not wanting smaller organizations' continued participation?
Smaller agencies will have a harder time getting noticed. The health plans will get calls every day from providers asking to be contracted. If you have board members who have contacts use them. Be the friendly nag about getting in to see the managed care organization, meet them whenever they have the time, -- whatever you need to do to get in the door and get that first contract. Getting that first contract is key because then you can use that as leverage with other managed care organizations. Secondly, smaller agencies can pull together as a collaborative and approach the managed care organization and say here is our full array of services with all these agencies and we're looking for one contract.
Can billing departments or billing systems automate codes based on keywords?
No, billing departments or billing systems cannot automate codes based on keywords.
Is there a way to find out what the Healthcare Effectiveness Data and Information Set (HEDIS) measures are going to be?
HEDIS scores are national quality measures and there are now, through CMS, penalties for not meeting certain HEDIS scores in physical health. Eventually that penalty will affect the behavioral health side as well. Most likely managed care organizations will be interested in behavioral health readmission, 7 and 30 day follow-up, and a medication adherence quality measure.
For more information on HEDIS, please go here. The 2016 HEDIS measures can be found here.
What is the recommended website/reading for providers to get briefed about the transition to managed care?
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.
Is there a reason that managed care organizations would not want to contract with a provider?
Managed care organizations may not want to contract with a provider because of geographical coverage, cost, or concerns about quality of care.
What are the billing codes and where are they located?
A draft manual for New York City is available here. All plans and providers will use the same coding construct which will crosswalk procedure code and modifier code combinations back to fee-for-service (FFS) rate codes.
Under a value based system, how will authorization work for individuals who struggle with severe mental illness and are doing well but do not demonstrate progress as it is traditionally known?
Symptom reduction may not always be the primary goal. The State will look at functional assessment and how the service that is being provided is creating a functional improvement to the client and their wellbeing. Managed care organizations will also pay attention, specifically, to how services keep individuals out of the hospital.
Are Managed Care Organizations (MCOs) required to contract with providers?
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.
Additional information on this can be found here, here and here.
Any advice for Home and Community Based Services(HCBS) in terms of contracting with managed care organizations?
There is nothing unique about HCBS from a contracting perspective, but from a quality perspective and an accountability perspective there is a lot of scrutiny over those services. For example, did the member receive what they were supposed to receive (i.e. hours)? Generally it's going to be the same contract template but with some unique features in terms of performance requirements that plans may be focused on. It's important that the providers capture and document the services. The plan also has to ensure that those services are being provided in the home and community based setting.
Are we moving towards a Per-Month-Per-Member (PMPM) environment or a Fee-for-Service (FFS) environment?
We are moving towards a PMPM environment. Managed Care Organizations (MCOs) receive a fixed monthly payment for each member which covers a defined set of services, or benefits. Please refer to slide 16, "How Managed Care is Paid," found here.
What about Medicare or dual eligible recipients?
Medicare recipients and dual eligible clients are currently carved out of the managed care transition.
How will HARP contracts vary from mainstream managed care contracts?
HARP plans have the same contractual requirements. There is not a separate HARP contract; it is the same as that of a mainstream managed care plan.
What is Level of Care for Alcohol and Drug Treatment (LOCADTR)?
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.
What is the definition of medical necessity?
The New York State Department of Health defines medically necessary as: "health care and services that are necessary to prevent, diagnose, manage or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap."
What is a Medical Loss Ratio (MLR)?
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.
What is the optimal background for the point person in the managed care contracting process?
Someone of a high level in the provider organization, who has broad knowledge of the organization and the members that you serve, and who can communicate with high levels within the managed care organization.
What can providers expect in terms of potential auditing from the managed care organizations?
This depends on the managed care organization so review your individual contracts. Managed care organization have the right to audit providers for various reasons. Specifically, reimbursement for services to make sure that there's documentation to support the claims that providers submit as well as for the quality measures that the plans are valuated on. Managed care organizations are entitled to reasonable access to information. Reasonable access presumably means notifying providers in advance, allowing providers to schedule the audit when they do not already have another plan auditing that day, and not interrupting or interfering with provider operations.