NYAPRS Note: The below overview of Ohio’s investment in Medicaid Redesign relevant to the behavioral health community offers a glimpse into another state’s process for determining a path forward toward inclusion of services and supports in a managed care environment. For advocates in areas where state mental health agencies are not immediately forthcoming with their plans and processes for changes in Medicaid service delivery, it is important to stay aware of other state’s practices to highlight how it has been done and to what advantages and disadvantages. Many departments are looking to the movements of NY, Ohio, and elsewhere to determine how to move forward with plans to integrate healthcare and take advantage of the ACA to implement new service approaches.
Ohio To Implement Medicaid Behavioral Health Redesign & 1915(i) Amendment For Adults With SPMI
Open Minds News Report; May 10, 2015
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On May 6, 2015, the Ohio Department of Medicaid released a request for comments on its proposed plan for a behavioral health redesign. The redesign calls for implementing a Medicaid 1915(i) amendment to provide a specialized set of home-and community-based services (HCBS) for adults with severe and persistent mental illness (SPMI) and income below 300% of the federal Supplemental Security Income (SSI) benefit level (about 225% of the federal poverty level). The 1915(i) amendment will preserve eligibility for Medicaid HCBS for adults with SPMI after the state Medicaid program implements a new single disability determination process for Medicaid services. The state estimates that between 4,000 and 6,000 individuals will meet the 1915(i) eligibility requirements. Comments on the proposed amendment will be accepted through June 6, and the proposal will be submitted for federal approval during June 2015.
The 1915(i) services will function as a wraparound to the beneficiary’s Medicare coverage, commercial health insurance, or health insurance marketplace plan. According to planning documents, the majority of people currently receiving Medicaid HCBS with incomes above the eligibility limit of 138% of the FPL are adults with SPMI. Current Medicaid beneficiaries who have incomes below the Medicaid eligibility limit will also be eligible for the 1915(i) services proposed in the amendment.
Ohio Medicaid requires all Medicaid-only beneficiaries to enroll in mandatory managed care plans. For people eligible for both Medicare and Medicaid who live in the regions participating in Ohio’s MyCare duals demonstration project, enrollment in a MyCare managed care plan is mandatory.
In addition to implementing the 1915(i) amendment, Ohio is planning to restructure all Medicaid-reimbursed behavioral health services under some form of managed care. Provider organizations in the new network will include community behavioral health organizations, inpatient hospitals, clinics, and specialty practitioners. Ohio Medicaid and the Ohio Department of Mental Health and Addiction Services (MHAS) will use one year of fee-for-service (FFS) experience and data from identifying the high risk/ high severity population in planning and rate setting for organizing all Medicaid-reimbursed behavioral health services under managed care.
The state seeks to begin implementing the redesign and the new disability determination process in state fiscal year 2016. The redesign plans call for redefining current behavioral health services and codes to align with national standards and to support integrated behavioral and physical health services. The goal is to align services according to a person’s acuity level and need. The redesign will result in disaggregating community psychiatric supportive treatment, case management, and health home services, which will functionally cancel the current behavioral health home program.
The proposed Medicaid 1915(i) amendment for adults with SPMI will allow the state to implement new eligibility requirements by January 2016 for adults age 21 and older who meet the financial, clinical, needs, and risk eligibility criteria specified below:
- Financial eligibility—Income at or below 300% of the SSI payment amount and a $20 personal needs disregard. In calendar year 2015, the monthly income maximum is $2,219.
- Clinical eligibility—Diagnosed with schizophrenia, bipolar, or major depressive affective disorders-severe. Persons may be eligible for 1915(i) services if they score a 2 or above on at least one of the items in the “mental health needs” or “risk behaviors” sections of the Adult Needs and Strengths Assessment (ANSA) or if they score a 3 on at least one of the items in the “life domain functioning” section. Clinical assessments will be conducted by community mental health agency clinical staff. Needs assessments for potentially eligible individuals will be conducted by Person Centered Care Planners (PCCPs) within a community mental health agency that are distinct from clinical staff.
- Risk eligibility—The criteria will include potential loss of eligibility, or the inability to access Medicaid eligibility for the provision of HCBS plan services to sustain community living – 1915(i) eligibility will be targeted to those people who are not otherwise eligible under another Medicaid category.
For those eligible, HCBS covered under 1915(i) include three key Medicaid services. The services will be provided on a FFS basis, outside the Medicaid managed care capitation rate. The three services are as follows:
- Recovery Management and Behavioral and Primary Healthcare Coordination
- IPS Supported Employment
- Peer Recovery Support
The Recovery Management and Behavioral and Primary Healthcare Coordination services will be provided by PCCPs. Because of the federal HCBS conflict of interest requirements, community mental health agencies performing the clinical and needs assessments cannot also provide the IPS Supported Employment and Peer Recovery Support services, unless that agency is the only entity within the region available and willing to provide those services.
In February 2015, the Ohio Office of Health Transformation released an outline of the overall behavioral health redesign in “Ohio 2016 & 2017 Budget Proposal To Rebuild Community Behavioral Health System Capacity.” The executive budget invests an additional $34 million in 2016 and $112.4 million in 2017 to support the redesign and new services. In general, lower acuity services coordinator support services will be defined for people with less intensive service needs. New services will be developed for people with high intensity service need, including assertive community treatment, intensive home-based treatment, high fidelity wraparound, peer services, supportive employment, and substance use disorder residential services. In addition to implementing the 1915(i) amendment, Ohio behavioral health redesign will make the following changes:
- Implement a standardized assessment tool to prioritize need; the tool will include an assessment of housing needs and employment-related supports not covered by Medicaid.
- Facilitate access to non-Medicaid housing supports and housing options; a key goal is helping people with behavioral health disorders avoid institutional care, and reduce the length of stay when institutional care is clinically necessary.
- Improve care coordination and outcomes through managed behavioral health care. Ohio Medicaid and the Ohio Department of Mental Health and Addiction Services (MHAS) have not made any final decisions on the specific requirements for care coordination and the types of managed care entity or entities that will be contracted for this purpose. A structured process to seek stakeholder input began in March 2015. The managed care initiative would begin in 2017; the cost is projected at $68.9 million.
- Preserve state hospital capacity to provide crisis services. The executive budget provides an additional $10 million per year in 2016 and 2017 specifically to support state hospital operations.
- Support community strategies for offenders with mental illness to improve connections between local jails, state hospitals, and treatment provider organizations in order to reduce transfers, improve safety and judicial oversight, and address strained capacity in both jails and state hospitals.
- Support cross-agency prevention and crisis intervention efforts, and provides funding for suicide prevention, and targets efforts on people leaving state psychiatric hospitals.
- Continue the Strong Families, Safe Communities partnership between the Department of Developmental Disabilities and MHAS; the program is focused on working with families in crisis with youth who are at-risk of being a danger to themselves and others due to unmanaged symptoms of mental illness or developmental disabilities.
A link to the full text of “Implementing a Medicaid 1915 (i) Program for Adults with Severe and Persistent Mental Illness in Ohio” may be found in The OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/050615ohio1915ispmi.htm.
A link to the full text of “Ohio 2016 & 2017 Budget Proposal To Rebuild Community Behavioral Health System Capacity” may be found in The OPEN MINDS Circle Library atwww.openminds.com/market-intelligence/resources/020515ohiomhredesign.htm.
For more information, contact:
- 1915(i) Amendment Comments, Ohio Department of Medicaid, Post Office Box 182709, Floor 5, Columbus, Ohio 43218; 800-364-3153; Fax: 614-466-6945; E-mail:HCBSfeedback@medicaid.ohio.gov; Website:http://medicaid.ohio.gov/RESOURCES/PublicNotices.aspx
- Eric R. Wandersleben, Director, Media Relations and Outreach, Ohio Department of Mental Health and Addiction Services, 30 East Broad Street, 36th Floor, Columbus, Ohio 43215; 614-728-5090; E-mail: Eric.Wandersleben@mha.ohio.gov; Website:www.mha.ohio.gov