Medicaid Coverage Strategies for

Services for Children & Families

Suzanne Fields, MSW, LICSW

Senior Advisor for Health Care Financing

SAMHSA

For the National Home and Community Based Services Conference,

September 2012

Overview

• Medicaid strategies

• Opportunities and challenges with each strategy

• State context including political environment, other

goals to achieve, current Medicaid platform

• Innovation is possible with any Medicaid strategy

Variation in Use of Medicaid Options

• 1915 a - Wraparound Milwaukee; Cuyahoga

County, OH

• Targeted Case Management - New Jersey

Administrative Case Management

• 1915 c - Maryland

• TCM & State Plan- Massachusetts

MA Context

• State plan & 1115 Waiver • MA operating under an 1115 since July 1999.

• Use of State Plan Amendment (SPA) for Targeted

Case Management (TCM) allowed for well-defined terms; service level & target group approval by CMS

• Managed Care delivery platform

• Lawsuit remedy services and TCM operate under SPA, and all other BH services operate under 1115

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• Approx 1.1 million Medicaid enrollees

• Approx 470,000 persons under 21 years old

• 6 managed care entities (MCEs) • 1 MBHO for the PCCM • 5 integrated PH & BH plans, some of which sub-contract

out BH

• Decision to not enroll “the class” into one MCE

MA Context

• Rosie D. v. Patrick , a class action lawsuit filed in 2001 on

behalf of children and youth with serious emotional

disturbance

• Alleged that MA Medicaid failed to meet obligations of the

EPSDT statute

• January, 2006, the Court found that MA Medicaid had not

provided sufficient: • Behavioral Health Screening in primary care

• Behavioral Health Assessments

• Service Coordination

• Home-based Behavioral Health Services

MA EPSDT Lawsuit

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• Final judgment issued June 2007 with implementation July 2009

• Medicaid as the sole financer-no blending/braiding with other state systems

Two key decisions: Services are available to all Medicaid covered youth; not

just “the class” (470,000 vs. 15,000)

Neither services or “the class” were limited to one MCE, but can opt for any of the five MCE’s available

MA EPSDT Lawsuit

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Four court-ordered requirements:

• Standardized Behavioral Health Screening by all

primary care providers to every child up to age 21

• Educate members, providers, public about Medicaid

covered services and how to access

• Implement Standardized Clinical Assessment, train

every clinician in the state and build a centralized IT

infrastructure to gather data

• Design and implement new BH services

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Screening

• Partnership with associations

• Training to all PCCs

• Implemented nine different screening tools

• Billing code modifier to indicate if positive for BH

issue

• Tracked referral to tx

• % of visits with screens 15% (2008) to 67% (2011). • In 2011 this represented 81,000-92,000 visits per Q

• Approx 8% need identified (only available if billing

modifier indicated)

Assessments

• Partnership with provider associations

• Training & certification process established

by state

• Selection and implementation of one tool-

CANS

• Used in OP, in-home therapy and Intensive

Care Coordination (TCM)

• Approximately 6,000 CANS per mo are

completed

• Targeted Case Management (TCM) (referred to as Intensive Care Coordination (ICC)

• Parent/Caregiver Peer to Peer Support (referred to as Family Partners)

• Behavior Management Monitoring

• Behavioral Management Therapy

• In-Home Therapy

• Therapeutic Mentoring

• Mobile Crisis Intervention

Medicaid Covered Services: New

Services

• TCM

• Inpatient Services

• Community Support Program (CSP)

• Partial Hospitalization

• Community-Based Acute Treatment for Children and Adolescents

• Acute Treatment Services for Substance Abuse (ASAM 3.7)

• Clinical Support Services-Substance Abuse (ASAM 3.5)

• Psychiatric Day Treatment

• Structured Outpatient Addiction Program (SOAP)

• Intensive Outpatient Program

• Outpatient Services (IT, FT, G, Bridge, Consultation, Telephone)

• Psychological Testing

• Emergency Services Program

Medicaid Covered Services –

Existing BH Services

Transformational Change of the Child

Behavioral Health System

FROM

• Professionally driven

• Deficit-focused

• Culturally neutral

• Office-based

• Reliance on

formal/paid supports

• Fragmented and

independent

TO

• Family/youth driven

• Strength-based

• Culturally competent

• Community-based

• Reliance on natural

supports and helpers

• Collaborative and

integrated

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• Executive Director of statewide chapter of

Federation of Families for Children’s Mental

Health sits on internal commissioner level

statewide planning and policy making body

• Participation at provider statewide meetings

• Family members on CBHI Advisory Council

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Family Involvement

Service Definition: Intensive Care Coordination

Intensive Care Coordination (ICC) provides a single point of accountability for

ensuring that medically necessary services are accessed, coordinated, and

delivered in a strength based, individualized, family/youth-driven, and ethnically,

culturally, and linguistically relevant manner. Services and supports, which are

guided by the needs of the youth, are developed through a Wraparound planning

process consistent with Systems of Care philosophy that results in an

individualized and flexible plan of care for the youth and family. ICC is designed to

facilitate a collaborative relationship among a youth with SED, his/her family and

involved child-serving systems to support the parent/caregiver in meeting their

youth’s needs. The ICC care planning process ensures that a care coordinator

organizes and matches care across providers and child serving systems to enable

the youth to be served in their home community.

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Service Definition: Intensive Care Coordination (cont’d)

ICC is defined as follows:

Assessment: The care coordinator facilitates the development of the Care Planning Team (CPT), who utilize

multiple tools, including a strength-based assessment inclusive of the Child and Adolescent Needs and

Strengths (CANS-MA version), in conjunction with a comprehensive assessment and other clinical information

to organize and guide the development of an Individual Care Plan (ICP) and a risk management/safety plan.

Development of an Individual Care Plan: Using the information collected through an assessment, the care

coordinator convenes and facilitates the CPT meetings and the CPT develops a child- and family-centered

Individual Care Plan (ICP) that specifies the goals and actions to address the medical, educational, social,

therapeutic, or other services needed by the youth and family.

Referral and related activities: Using the ICP, the care coordinator convenes the CPT which develops the ICP;

works directly with the youth and family to implement elements of the ICP; prepares, monitors, and modifies

the ICP in concert with the CPT; will identify, actively assist the youth and family to obtain, and monitor the

delivery of available services including medical, educational, social, therapeutic, or other services; develops

with the CPT a transition plan when the youth has achieved goals of the ICP; and collaborates with the other

service providers and state agencies (if involved) on the behalf of the youth and family.

Monitoring and follow-up activities: The care coordinator will facilitate reviews of the ICP, convening the CPT

as needed to update the plan of care to reflect the changing needs of the youth and family. The care

coordinator working with the CPT perform such reviews and include whether services are being provided in

accordance with the ICP; whether services in the ICP are adequate; and whether these are changes in the

needs or status of the youth and if so, adjusting the plan of care as necessary.

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Service Definition: Family Partner

Family Support and Training is a service provided to the parent /caregiver of a youth

(under the age of 21), in any setting where the youth resides, such as the home (including

foster homes and therapeutic foster homes), and other community settings. Family Support

and Training is a service that provides a structured, one-to-one, strength-based relationship

between a Family Partner and a parent/caregiver. The purpose of this service is for resolving or

ameliorating the youth’s emotional and behavioral needs by improving the capacity of the

parent /caregiver to parent the youth so as to improve the youth’s functioning as identified in

the outpatient or In-Home Therapy treatment plan or Individual Care Plan (ICP), for youth

enrolled in Intensive Care Coordination (ICC), and to support the youth in the community or to

assist the youth in returning to the community. Services may include education, assistance in

navigating the child serving systems (DCF, education, mental health, juvenile justice, etc.);

fostering empowerment, including linkages to peer/parent support and self-help groups;

assistance in identifying formal and community resources (e.g., after-school programs, food

assistance, summer camps, etc.) support, coaching, and training for the parent/caregiver.

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Service Definition: Mobile Crisis

Mobile Crisis Intervention is the youth (under the age of 21)-serving component of an

emergency service program (ESP) provider. Mobile Crisis Intervention will provide a short-term

service that is a mobile, on-site, face-to-face therapeutic response to a youth experiencing a

behavioral health crisis for the purpose of identifying, assessing, treating, and stabilizing the

situation and reducing immediate risk of danger to the youth or others consistent with the

youth’s risk management/safety plan, if any. This service is provided 24 hours a day, 7 days a

week. The service includes: a crisis assessment; development of a risk management/safety

plan, if the youth/family does not already have one; up to 72 hours of crisis intervention and

stabilization services including: on-site face-to-face therapeutic response, psychiatric

consultation and urgent psychopharmacology intervention, as needed; and referrals and

linkages to all medically necessary behavioral health services and supports, including access

to appropriate services along the behavioral health continuum of care.

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Service Definition: Behavior Management Therapy

Behavior Management Therapy: This service includes a behavioral assessment

(including observing the youth’s behavior, antecedents of behaviors, and

identification of motivators), development of a highly specific behavior treatment

plan; supervision and coordination of interventions; and training other interveners

to address specific behavioral objectives or performance goals. This service is

designed to treat challenging behaviors that interfere with the youth’s successful

functioning. The behavior management therapist develops specific behavioral

objectives and interventions that are designed to diminish, extinguish, or improve

specific behaviors related to the youth’s behavioral health condition(s) and which

are incorporated into the behavior management treatment plan and the risk

management/safety plan.

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Service Definition: Behavior Management Monitoring

Behavior Management Monitoring: This service includes implementation of

the behavior treatment plan, monitoring the youth’s behavior, reinforcing

implementation of the treatment plan by the parent(s)/guardian(s)/caregiver(s), and

reporting to the behavior management therapist on implementation of the

treatment plan and progress toward behavioral objectives or performance goals.

Phone contact and consultation may be provided as part of the intervention.

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Service Definition: In-Home Therapy Services

In-Home Therapy is a structured, consistent, strength-based therapeutic relationship between a

licensed clinician and the youth and family for the purpose of treating the youth’s behavioral health

needs, including improving the family’s ability to provide effective support for the youth to promote

his/her healthy functioning within the family. Interventions are designed to enhance and improve the

family’s capacity to improve the youth’s functioning in the home and community and may prevent the

need for the youth’s admission to an inpatient hospital, psychiatric residential treatment facility or

other treatment setting. The In-Home Therapy team (comprised of the qualified practitioner(s), family,

and youth), develops a treatment plan and, using established psychotherapeutic techniques and

intensive family therapy, works with the entire family, or a subset of the family, to implement focused

interventions and behavioral techniques to: enhance problem-solving, limit-setting, risk

management/safety planning, communication, build skills to strengthen the family, advance

therapeutic goals, or improve ineffective patterns of interaction; identify and utilize community

resources; develop and maintain natural supports for the youth and parent/caregiver(s) in order to

promote sustainability of treatment gains.

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Service Definition: In-Home Therapy Services

In-Home Therapy is provided by a qualified clinician who may work in a team that includes one

or more qualified paraprofessionals.

Therapeutic Training and Support is a service provided by a qualified paraprofessional working

under the supervision of a clinician to support implementation of the licensed clinician’s

treatment plan to assist the youth and family in achieving the goals of that plan. The

paraprofessional assists the clinician in implementing the therapeutic objectives of the

treatment plan designed to address the youth’s mental health, behavioral and emotional needs.

This service includes teaching the youth to understand, direct, interpret, manage, and control

feelings and emotional responses to situations and to assist the family to address the youth’s

emotional and mental health needs. Phone contact and consultation are provided as part of the

intervention. In Home Therapy Services may be provided in any setting where the youth is

naturally located, including, but not limited to, the home (including foster homes and

therapeutic foster homes), schools, child care centers, respite settings, and other community

settings.

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Service Definition: Therapeutic Mentoring

Therapeutic Mentoring Services are provided to youth (under the age of 21) in any setting

where the youth resides, such as the home (including foster homes and therapeutic foster

homes), and in other community settings such as school, child care centers, respite settings,

and other culturally and linguistically appropriate community settings. Therapeutic Mentoring

offers structured, one-to-one, strength-based support services between a therapeutic mentor

and a youth for the purpose of addressing daily living, social, and communication needs.

Therapeutic Mentoring services include supporting, coaching, and training the youth in age-

appropriate behaviors, interpersonal communication, problem-solving and conflict resolution,

and relating appropriately to other children and adolescents, as well as adults, in recreational

and social activities pursuant to a behavioral health treatment plan developed by an outpatient,

or In-Home Therapy provider in concert with the family, and youth whenever possible, or

Individual Care Plan (ICP) for youth with ICC. These services help to ensure the youth’s

success in navigating various social contexts, learning new skills and making functional

progress, while the Therapeutic Mentor offers supervision of these interactions and engages

the youth in discussions about strategies for effective handling of peer interactions.

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Using Managed Care

• MCEs selected a common network of ICC & Family Partner providers (unlike other BH services in which provider networks differ across the MCEs)

• All service descriptions were developed as part of the lawsuit and were adopted by the MCEs

• MCEs released an Operations Manual developed by the state on wraparound practice, responsibilities of providers in delivering ICC and Family Support services

Usinf Managed Care • Convened weekly MCE workgroup meetings to

identify commonalities: o Provider network o Clinical review questions/inter-rater reliability testing o Billable activities definitions o Authorization parameters (time period and # of units) o Common reporting (required elements, data dictionary,

quality checks)

• Held individual UM meetings with each of the plans to provide technical assistance on issues unique to that plan

Using Managed Care

• Held multiple trainings for MCE staff AND the provider community on the Wraparound process (Wrap 101), the new services, and the vision of the Children’s Behavioral Health Initiative

• MCEs held harmless for first year

• MCEs created common clinical review questions & a common inter-rater reliability test for clinical review staff

• Clinical review questions were tied to Wraparound fidelity (e.g. natural supports on the team, brainstorming of options occurred, sustainability of services / supports considered, etc.)

Managed Care & Wraparound

• Concerns that managed care processes

would upset the integrity of the care

planning process for youth and their

families in ICC:

o Prior authorization procedures

o Service denials

oRole and expertise of the team, especially of

natural supports

o Family voice about their needs

oUnconditional efforts until something works

• MCE capitated payments • No risk for first year--added payment guaranteed

• This also reduced disincentives to authorization process

• Rate-setting process • Benchmarked to existing service rates

• Public comment

• 15 minute unit vs. bundled or case rates

• CMS considerations

Financing Structure and

Payment Approaches

• Start-Up Costs • Planning, contract with purveyor, meetings with providers

• Infrastructure Costs • Training, coaching, supervision; fidelity monitoring, outcome

measurement, technology

• Direct Service Costs

• Clinical, non-clinical such as room and board, non-Medicaid children

• Options: Medicaid, IV-E, TANF, Cross-agency general revenue, Grants, Medicaid MCO profits or admin, cross-agency dollars

Medicaid Alone Is Not

Sufficient

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Wrap Up

• Additional resources on MA approach:

www.mass.gov/eohhs/gov/commissions-and-initiatives/cbhi/

• Additional resources on other states approaches

www.county.milwaukee.gov/WraparoundMilwaukee.htm

www.performcarenj.org/

www.ssw.umaryland.edu/theinstitute

www.cuyahogatapestry.org/en-US/contact.aspx

• Other national resources:

www.chcs.org/

www.gucchd.georgetown.edu/