Smokey Mountain MCO Mental Health & SA Providers

Smokey Mountain Provider Network Bulletin

Mental Health and Substance Abuse providers: Home Based Therapy (90837 SR)

 

Smoky has identified a need in the Smoky Benefit Plan(s) for a Mental Health/Substance Abuse (MH/SA) clinical service that can be provided in a consumer’s home to maximize effectiveness of care for individuals who face certain barriers to office-based therapy. Effective January 1, 2015, basic benefit 60 minute therapy (90837 + SR) will be available in both the Medicaid and State Benefit Plans at a rate of $112 for all license types. This specialized service will be made available to Medicaid and State funded consumers in all disability groups (MH/SA/IDD) who are unable to benefit from traditional office based treatment and who meet all General, Entrance, Continued Stay and Discharge Criteria as required for Outpatient Behavioral Health Services in DMA Clinical Coverage Policy 8C.

 

Home Based Therapy (90837 SR) requires face-to-face service delivery and may be used when a consumer’s need requires outpatient level-of-care. The service is not intended to address cognitive or intellectual/developmental issues that would not benefit from outpatient therapy services.   This 60-minute psychotherapy code requires the focus of the service delivery to be on the individual; however, it can be used with the occasional involvement of family members. In addition, providers of this service must be trained in and follow a rehabilitative best practice or evidence-based treatment model consistent with community practice standards. The selected treatment model must produce positive outcome for the consumer’s diagnosis and needs.

 

State funded consumers may access this service through Smoky’s regional Comprehensive Care Centers. Smoky will continue to evaluate the need for further expansion of this service; Network Providers who would like to have this code added to their contract are encouraged to contact their Account Specialist for consideration.

 

In addition to meeting all Entrance, Continued Stay and Discharge Criteria found in Clinical Coverage Policy 8C the following criteria are required:

 

  • A Comprehensive Clinical Assessment must be completed prior to the delivery of Home Based Therapy and must demonstrate necessity for Home Based Therapy to meet the consumer’s treatment needs.
  • The consumer cannot be safely and effectively treated in a provider’s office, and reasonable attempts at office based or community based treatment are documented in the consumer’s record. A failure to attempt office based or community based treatment prior to accessing this service will result in denial of authorization or recoupment. Examples of where this criteria are met include the following:
    • A consumer who is considered high risk, for example with multiple Emergency Department or after hours crisis visits, who fails to maintain/engage in routine office based treatments.
    • A consumer with a phobia or other MH/SA condition that impedes access to traditional office based therapy.
    • A consumer who has received a high level enhanced service (i.e. ACTT) for an extended period of time and who has been stabilized but who will not engage in office based treatment.
    • A child who is deemed at risk for out of home placement but does not meet other qualifiers for Intensive In Home Services. In addition, all attempts at engagement with parent or guardian have been unsuccessful.
    • A consumer with co-occurring IDD/MH diagnosis who presents with physical conditions that impede access to traditional office based treatment.
    • A consumer who requires treatment for a MH/SA condition but is unable to access office treatment due to lack of transportation. If the service is required due to a lack of transportation to attend office based treatments, all transportation alternatives, including use of public transportation, Medicaid transportation for Medicaid recipients, and natural supports must be unavailable to the recipient.
  • This service can be reasonably expected to be effective in addressing the recipient’s diagnosed mental health or substance use disorder.
  • Without Home Based Therapy Service, there is an identified, specific, significant health and/or safety risk to the individual OR an identified, specific, significant risk of physical or mental harm to immediate family or community; or the consumer is at risk of out of home placement and/or may require a higher level of care.

 

Consumers who meet eligibility requirements for this specialized Home Based Therapy may receive up to 8 unmanaged visits. All applicable documentation requirements must be met for all visits, including the 8 unmanaged visits, and must demonstrate the alternatives that were accessed prior to utilizing Home Based Therapy. To request beyond the 8 unmanaged visits providers must submit a Service Authorization Request (SAR) along with the CCA. Authorization guidelines will permit up to 26 sessions for a 90 day period as medically necessary. This is viewed as a time limited service to be titrated as a consumer becomes engaged in traditional community based services.

 

If this service is added to your contract, any questions about authorization should be directed to the Care Management Department at 1-800-893-6246 ext. 1513. Providers with questions about contracts please contact your Account Specialist or call 866-990-9712.

Medicaid Reform Report Published

The General Assembly Subcommittee on Medicaid Reform published its report this week. Here is the contents of the report:

FINDING 1: REFORM OF THE MEDICAID AND HEALTH CHOICE PROGRAMS IS NEEDED TO ADDRESS THE RISING OVERALL COSTS OF THE PROGRAMS
The efficient and effective delivery of Medicaid and Health Choice services is of vital importance to Medicaid and Health Choice beneficiaries, the Department of Health and Human Services, Members of the General Assembly, and the citizens of the State. The Medicaid and Health Choice budget represents a significant portion of the State budget, and reliable forecasting is imperative to sustainable funding. The Subcommittee on Medicaid Reform/Division of Medical Assistance (DMA) Reorganization reviewed legislation considered during the 2014 Session, heard from three states on their approaches to reform and Medicaid service delivery, and received comments from stakeholders. The Subcommittee received a Medicaid budget analysis from Steve Owen of the Fiscal Research Division demonstrating that the current fee-for-service Medicaid model will continue a trend of constantly increasing Medicaid costs. Medicaid Directors from Florida, Ohio, and Virginia, presented examples of how increased care management in their states has helped to control Medicaid costs.

RECOMMENDATION 1: REFORM OF THE MEDICAID AND HEALTH CHOICE PROGRAMS IS NEEDED TO ADDRESS THE RISING OVERALL COSTS OF THE PROGRAMS
The Subcommittee on Medicaid Reform/Division of Medical Assistance (DMA) Reorganization, Joint Legislative Oversight Committee on Health and Human Services, recommends that the Joint Legislative Oversight Committee recommend that the General Assembly support the enactment of legislation by the General Assembly during the 2015 Session to accomplish reform of the Medicaid and Health Choice programs to a new health care system that will, within three years, achieve all of the following features:

• Shared Financial Risk. The new health care system should share the financial risk between the State and providers and contractors by shifting 100% of the utilization risk to providers or other contractors within three years, while the State should continue to bear the risk for changes in the number of eligible beneficiaries. Joint Legislative Oversight Committee on Health and Human Services Page 8 Subcommittee on Medicaid Reform/Division of Medical Assistance Reorganization

• Defined, Measureable Goals for Health Outcomes, Quality of Care, and Cost. The new health care system should define measurable goals for health outcomes, quality of care, and cost, based on appropriate local, national, and industry standards. The goals should be designed to allow the program to measure progress toward the goals, to increase comparability of services, and to achieve greater budget predictability for the State. Payment methodologies should reflect a relationship between reimbursement and the defined goals.

• Accountability for Coordinated Care, Positive Health Outcomes, and Controlling Costs. The new health care system should operate like a health insurance company in that the program is held accountable for ensuring coordinated care across the entire health care continuum and for producing positive health outcomes while controlling utilization costs. In order to hold the program accountable, the General Assembly should delegate the authority to control all payment rates, policies, and methodologies, as well as the scope and level of covered services provided, within the budget approved by the General Assembly. The program should not be held accountable for the growth and mix of the population of eligible beneficiaries, and the General Assembly should retain control of Medicaid and Health Choice eligibility criteria and thresholds.

• Regional Access to Care. The new health care system should ensure continuity of access to care across the State and address local needs through regional, financially sustainable organizations. The program should assure an adequate supply of appropriate providers within reasonable proximity of all beneficiaries, and should address the unique needs of both urban and rural communities. To this end, preference should be given to provider-led organizations that can achieve all of the reform goals.

• Administrative Efficiencies. Administrative policies and procedures utilized by the new health care system should minimize duplication, minimize consumption of the total Medicaid dollar, and support effective monitoring, enforcement, and decision-making. Administrative policies and procedures should be designed to achieve the most efficient program administration possible at the lowest reasonable cost to the State, thereby increasing the overall value of the Medicaid and Heath Choice program dollars spent.

Tillis no longer against medicaid expansion

From the Charlotte Observer:

In last spring’s Republican primary, U.S. Senate candidate Thom Tillis ran an ad touting his fight against an expanded Medicaid program.

“Thom Tillis has a proven record fighting against Obamacare,” the narrator said. “Tillis stopped Obama’s Medicaid expansion cold. It’s not happening in North Carolina, and it’s because of Thom Tillis.”

But this week Tillis struck a different note.

“It wasn’t like I had an ideological objection to expanding Medicaid,” he told Time Warner Cable News. “We’re trending in a direction where we should consider potential expansion. … I would encourage the state legislature and the governor to consider it.”

Democrats were quick to cry flip-flop.

“Tillis has done a complete 180,” MSNBC’s Ed Schultz said this week. “Talk about a change of heart.”

The change comes as state leaders across the country who once rejected the idea – along with the federal dollars that came with it – face increasing pressure to reverse course and expand the program that provides medical care to the poor.

Last month, Public Policy Polling, a Democratic-leaning firm in Raleigh, found that 57 percent of likely N.C. voters support expansion while 28 percent oppose it.

The debate also returns health care to the headlines in the nation’s most expensive U.S. Senate race. It was over a year ago that outside groups first ran ads criticizing Democratic Sen. Kay Hagan over her support of the Affordable Care Act.

Tillis’ campaign says his position, like that of Gov. Pat McCrory, has evolved as administration officials say management problems have improved at the state Department of Health and Human Services.

As House speaker, Tillis cited problems at DHSS and doubts about the cost in pushing to reject Medicaid expansion. Under the ACA, the federal government would have covered the cost of expanding the program to 500,000 North Carolinians for three years and paid 90 percent after that.

Now, hospitals are forced to treat many uninsured patients for free, which in turn raises prices for paying patients.

“Based on the previous state of the system, expansion would have eventually caused massive budget deficits, resulting in severe cuts to other important programs,” said Tillis spokesman Daniel Keylin. “(Now) the state’s Medicaid system is in a much better position.”

But pressure has built on state leaders like Tillis.

A report published in August by the Robert Wood Johnson Foundation and the Urban Institute said North Carolina stood to lose $39.6 billion in Medicaid funding over the next decade while N.C. hospitals would lose $11.3 billion in lost reimbursements.

In September, PricewaterhouseCoopers’ Health Research Institute said hospitals in states that did expand coverage saw a significant rise in the number of paying customers and drop in the level of uncompensated care.

By contrast, hospitals in North Carolina and the 23 other states that did not expand Medicaid saw “flat or sagging admission rates and little reduction in the number of uninsured, largely non-paying patients.”

For hospitals, expansion means more reimbursed care.

“We are pushing for expansion both in North and South Carolina,” said Martha Ann McConnell, a lobbyist with Carolinas HealthCare System. “Our message has been pretty consistent. We’re already paying for it both as citizens and as providers … and not realizing the benefit.”

In August, Gallup found that Arkansas and Kentucky led states in reducing their number of uninsured. Both states had expanded their Medicaid programs.

North Carolina DHHS Secretary Aldona Wos recently announced a $63 million budget surplus for the state’s Medicaid program. This month she told the Observer that along with some concessions by the government, that may open the door to eventual expansion.

Last October, McCrory rejected a request to call lawmakers into special session to deal with expansion. Tillis and Senate President Pro Tem Phil Berger issued a statement saying expansion would cost “hundreds of millions of dollars” over a decade.

“How do these Democratic Party front groups suggest we pay for it?” the GOP leaders said. “How many teachers are they willing to fire?”

Hagan spokeswoman Sadie Weiner said Tillis is “trying to have it both ways …”

Jonathan Oberlander, an associate professor of health policy administration at UNC Chapel Hill, said, “There’s no question it’s a flip-flop, and in my view one that’s long overdue.”

“No question it is really hurting North Carolina hospitals,” he said. “And there’s a growing realization how much it hurts the state not to expand.”

N.C. lags on housing issue

Feds want eligible people with mental-health challenges moved out of adult-care homes

Posted: Saturday, October 11, 2014 9:02 pm

Richard Craver/Winston-Salem Journal

North Carolina appears to be making slower progress than other states in complying with a federal requirement to move eligible residents with mental-health challenges from adult-care homes to independent housing.

The initiative is the latest development in the Olmstead legal case, which involves the U.S. Justice Department and the integration aspect of the Americans With Disabilities Act.That aspect is intended to provide individuals with disabilities the opportunity to live their lives like those without disabilities. North Carolina and Justice officials reached an agreement in August 2011 on allegations North Carolina was violating the act. The transition initiative was a key part of the settlement.

Eligible to participate are people living in adult-care homes with a diagnosis of serious and persistent mental illness, or those who have been in treatment for more than 90 days at a state hospital.

Federal officials have reached similar settlements in Ohio and Virginia, two of three states whose Medicaid directors made presentations Monday to a N.C. legislative subcommittee about their reform efforts. The third state, Florida, remains in litigation with the federal agencies.

Nine managed-care organizations (MCOs) in North Carolina, including CenterPoint Human Services, have until 2021 to move about 3,000 individuals. CenterPoint oversees behavioral health services in Davie, Forsyth, Rockingham and Stokes counties.

The transition initiative began in the spring of 2013. The MCOs are responsible for arranging care coordination; suitable safe housing with developers and realty companies, including a rental subsidy; and services for individuals, including moving expenses. Each person receives $2,000 in transition costs.

The N.C. Department of Health and Human Services said Tuesday that 317 individuals statewide have been placed in home or community housing settings, or just more than 10 percent.

That includes 33 individuals in CenterPoint’s area, ranking it fifth among the nine MCOs. There are another 193 in the transition process, including two in CenterPoint, ranking it last. CenterPoint is required to move at least three individuals a month.

“Each individual, and thus each case, is unique, which makes it challenging to make for a smooth transition and still meet the mandate,” Dr. Chad Stephens, CenterPoint’s medical director, said in June.

DHHS spokesman Kevin Howell said the statewide transition total is 273 as of Oct. 1. He said 21 individuals have moved into a more restrictive level of care, 13 moved in with family, moved out of state or into another independent living arrangement, seven have died and three are in a state hospital.

By comparison, Ohio surpassed this summer the 5,000 mark of transitioned individuals through the Home Choice initiative launched in 2008. The initial goal was transferring 2,000. In 2013, Ohio had the nation’s second highest number of transitioned individuals, as well as the highest number of those with mental health issues.

Virginia is obligated to move about 4,170 individuals, according to a federal report update in April. The total number of transitioned individuals was not available. Most individuals are those with intellectual and non-intellectual disabilities.

John McCarthy, Ohio’s Medicaid director, said the state’s spending for affected individuals is at 51 percent for home and community based settings and 49 percent for institutional settings. He said the initiative is an example of where “the money follows the person.”

“The reason this took off is that we hired a housing coordinator, and so did mental health,” McCarthy said. “They had lived in nursing homes because they had no other place to go. They now qualify for vouchers for rents and other costs.”

The independent auditor for the Virginia initiatives said the state “has achieved compliance with many provisions of the agreement.” That includes creating and distributing more than the minimum required number of waiver slots, and placing at least 310 individuals in community housing settings as of April.

“Despite these efforts, the Commonwealth is significantly behind schedule with repeated delays in complying with certain obligations,” the auditor said. “It is essential the Commonwealth redouble its efforts and expedite its plans to meet its commitments.”

Virginia Gov. Terry McAuliffe has made creating behavioral health homes for people with serious mental illness a top health-care priority for his administration.

“Our goal has been to move more people into community setting and not let them in the nursing home in the first place with preadmission screening,” said Cindi Jones, Virginia’s Medicaid director.

A CenterPoint human-rights committee submitted a letter to N.C. DHHS officials in January that sought assistance in helping it get relief from the federal mandate. CenterPoint Chairman Bryan Thompson said last week the agency’s human right committee met with state health officials on the issue

“We got a full on presentation from DHHS that provided alternatives and resolved the issues,” Thompson said.

Vicki Smith, executive director of Disability Rights N.C., said it appears CenterPoint wants DHHS “to draw a line and say, ‘These people are too fragile. Don’t bother with them.’ ”

“We know (the MCOs) had a slow start. We expect that they will hit their targets this year.”

New hope for deal on Medicaid

New hope for deal on Medicaid

Posted: Wednesday, Oct. 08, 2014

Good news for the hundreds of thousands of truck drivers, janitors, day-care attendants, fast-food servers and other low-income workers in North Carolina: Gov. Pat McCrory and the legislature may soon reconsider their long-standing opposition to Medicaid expansion.

Aldona Wos, the state Health and Human Services secretary, told the Observer editorial board Wednesday that with some flexibility from the federal government on how things are structured, a half-million or so state residents could become newly eligible for health insurance.

“We really are evaluating the different options and will be presenting them to the governor,” Wos said, echoing what she has told others in recent weeks. “But the road to the end result is a rather long road.”

This marks a dramatic and important turnaround. McCrory, Wos and Republican legislative leaders opposed Medicaid expansion from the first time they considered that provision of the Affordable Care Act. Now they might be open to it, attracting more than $30 billion of federal money in the next eight years to provide health insurance to 300,000 to 500,000 residents – at very little cost to N.C. taxpayers.

McCrory said all along that the state’s Medicaid program was “broken” and so shouldn’t be expanded. He also worried that the federal government wouldn’t live up to its promise to pay 100 percent of the cost for the first three years and 90 percent for years after that.

But Wos recently announced a $63 million budget surplus for the state’s Medicaid program. She told the editorial board that the program is on sound footing and so now expansion is worth considering.

“We obviously have stabilized the department … in a meaningful way,” she said. As for trusting the federal government to hold up its end of the deal, Wos praised other states that have proposed a “clever” solution: Agree to expand Medicaid, but tell the feds the state will quit the minute the federal funding dries up.

Wos and N.C. Medicaid Director Robin Cummings suggested Wednesday that whether North Carolina expands Medicaid will hinge to a great degree on how flexible the federal government is in allowing the state to craft a plan with certain features. They said it’s too early to say precisely what those would be, but said that they would want to incorporate an element of “personal responsibility” on the part of the Medicaid recipient. That could mean rewarding a person for good behavior like losing weight and penalizing her for bad behavior like going to the emergency room for routine care.

North Carolina should have accepted Medicaid expansion long ago rather than make a political statement against Obamacare at the expense of hard-working North Carolinians. It was a good financial deal for the state, and it would have encouraged cheaper preventative care for low-income residents before they encountered more serious problems.

It’s not too late, though. With face-saving measures included or not, Gov. McCrory and legislative leaders can still do the right thing.
Read more here: http://www.charlotteobserver.com/2014/10/08/5229157/new-hope-for-deal-on-medicaid.html#.VDaTnlwcG68#storylink=cpy

LOC Hears from Other States About Medicaid

State officials hear Medicaid options from three states

Posted: Monday, October 6, 2014 2:35 pm

Richard Craver/Winston-Salem Journal

RALEIGH – There is no one-size-fits-all approach to Medicare reform, particularly with privatization, according to three states that shared with a N.C. legislative subcommittee how they are plowing forward.

Medicaid directors from Florida, Ohio and Virginia were asked to make presentations in Raleigh on Monday in hopes of helping the N.C. House and Senate find elements for compromise in their struggle to set a viable reform path.

State Senate leaders say the way to fix Medicaid runs primarily through privatization. The Florida managed care initiative is the closest to what the Senate favors, Sen. Ralph Hise, R-McDowell said.

House leaders, state health Secretary Dr. Aldona Wos and Gov. Pat McCrory prefer having providers and health-care systems involved as an accountable care organization — with a larger risk-reward expenditure role.

The N.C. Medicaid program was estimated to cost $13.6 billion in fiscal 2013-14, covering more than 1.85 million individuals.

By comparison, Florida has a $23 billion budget with 3.6 million recipients, Ohio has a $24.8 billion budget for 2.5 million and Virginia has an $8.4 billion budget for 1 million.

Ohio spun its Medicaid program into a separate department — as N.C. Senate leaders propose — with its director rising to cabinet-level status. Virginia has kept its program with its Department of Health and Human Services.

Justin Senior, Florida’s Medicaid director, said that since 2011, the state has moved from 52 managed care organizations (MCOs) to 14 – seven of which offer comprehensive plans statewide and seven that offer all but long-term care. The state is divided into 11 regions, whereas North Carolina likely will be divided to no more than seven, though that has not been finalized.

Senior said that before Medicaid reform, there was a “come one, come all” approach with MCOs. “They could come and go as they pleased business wise,” he said.

That has been the top concern of opponents of privatizing N.C.’s program, particularly providers and health-care systems.

Senior said Florida guarded against MCOs “cherry picking” where they wanted to do business in part by offering a higher rate for those that have better outcomes treating “the sickest of the sick.”

“If a MCO pulls out of one region, they are terminated in all regions,” Senior said. “Our accountable care organizations typically are associated with health care systems and they aren’t going anywhere.”

Senior said MCOs had to agree that 95 percent of providers in their network would have to accept new patients, and physicians had to agree to extend business hours to 8 p.m. and weekends to help reduce the influx of emergency department patients. He said physician groups can be sanctioned for noncompliance.

John McCarthy, Ohio’s Medicaid director, said it consolidated regions from eight to three with five statewide MCOs and no accountable care organizations.

“Change has been difficult, but providers are seeing the benefits — new ways to be paid for quality results rather than the same rate as those providers with poorer quality,” McCarthy said,

Cindi Jones, Virginia’s Medicaid director, said its program cannot run a shortfall by General Statute, whereas North Carolina had cost overruns of at least a combined $2 billion from fiscal years 2009 to 2013.

Wos told legislators in September that N.C. DHHS had a $63 million surplus in fiscal 2013-14. DHHS has provided few details on how that the surplus was accomplished.

“We monitor our costs closely on a weekly basis to see trends,” Jones said.

Virginia has to provide the governor and its legislature with a Medicaid spending forecast for the next three fiscal years by Nov. 15 each year.

“We only spend what we are provided, but we ask for more money every year,” Jones said.

By comparison, one of the main legislator complaints against Wos and DHHS is the inability of NCTracks, the state’s Medicaid claims-processing system, to provide any resemblance of budget predictability since launching in 2013.

Virginia, now under a Democratic administration, is moving toward Medicaid expansion, Jones said the state is trying to counter the perception that its Medicaid program is broken “when it is working and improving.”

McCrory has made among his governing principles that N.C.’s program is broken and has to be fixed before expansion can be considered. He said Medicaid cost overruns has limited spending in other areas of government, such as public education.

Rep. Donny Lambeth, R-Forsyth, said he heard encouraging items from each state.

“I believe we eventually will reach a compromise with the Senate, and sessions like this will help us see what aspects of other states’ efforts are working and may work here,” Lambeth said.

“What I would like to see us do for the next session is hear from some providers about their concerns and their suggestions, particularly on how we make sure rural North Carolina gets similar coverage as urban.”

Adam Linker, an analyst with N.C. Justice Center, said the presentations demonstrate “there is no magic bullet or secret sauce for saving money in health care.”

“Like all insurance plans, Medicaid in every state is constantly changing and reforming. We can’t wait for reform before we expand Medicaid. Reform and expansion have to be packaged together.”