Division of Medical Assistance: Integrated Care Workgroup Courtney Cantrell, PhD

NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina

DMA

Division of Medical Assistance: Integrated Care Workgroup

Courtney Cantrell, PhDAssistant Director for Behavioral Health

Division of Medical Assistance (DMA)

medicaidnorthcarolinamedicaidnorthcarolina

DMA

Division of Medical Assistance

• The mission of the Division of Medical Assistance (DMA) is to provide access to high quality, medically necessary health care for eligible North Carolina residents through cost-effective purchasing of health care services and products.

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Medicaid & NCHC Programs• Medicaid is a health insurance program for low-income

individuals and families who cannot afford health care costs. Medicaid serves low-income parents, children, seniors, and people with disabilities. ***Stay enrolled!!

• N.C. Health Choice for Children (NCHC) is a free or reduced price comprehensive health care program for children.– ***NC Tracks!! http://www.ncmmis.ncdhhs.gov 

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Medicaid Policy

• Subject to Federal Laws and Social Security Act, as well as state statutes; often follows Medicare

• State plan submitted to Centers for Medicare and Medicaid Service (CMS) for approval (unmanaged visits, services covered, providers who can provide services, etc)

• WAIVERS – allow us more flexibility to do things that would not be approved in a regular state plan

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Medicaid Waivers

• Waive provisions of Social Security Act (SSA)

– Each waiver number refers to a section of SSA– Each waives provisions of Section 1902

(requirements for State Plans)

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NC Medicaid Waiver for MH/SA/IDD Services• Medicaid Program follows Title XIX of the SSA• Medicaid Managed Care Program under CFR 438• DMA gets a 1915b/c waiver from CMS (Centers for

Medicare & Medicaid)• (b) waiver allows DMA to contract with a managed care

vendor (LME) for oversight of mh/sa/dd services in their counties.

• PIHP: Prepaid Inpatient Health Plan• (c) Waiver allows DMA to offer HCBS (habilitation)

• DMA monitors the company (LME-MCO) to make sure that they follow all Medicaid rules.

• CMS monitors DMA (follow SSA)

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5

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Covered Benefit Package

• All services found in the 8x series of DMA Clinical Coverage Policies - -regular outpatient and enhanced services***

• LME-MCO cannot be more restrictive than DMA Clinical Coverage Policy

• Audits should be based at least on DMA policy

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Covered Benefit Package

– Inpatient Behavioral Health Services (DMA Clinical Coverage Policy 8B)

– Inpatient services for the treatment of mental health and substance abuse disorders and developmental disabilities

– Hospital Emergency Department (ED) services: Each LME-MCO is responsible for all facility, professional, and ancillary charges for services delivered in the emergency department to individuals with a discharge diagnosis ranging from 290 to 319.

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Covered Benefit Package

– Outpatient Behavioral Health Services including all services provided by psychiatrists for recipients with a diagnosis in the 290-319 range (DMA Clinical Coverage Policy 8C)

• Excluded: E&M codes by physicians (except psychiatrists) –even if dx is 290-319

• NOTE: Co-located BH providers will need to enroll with the LME-MCO

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Covered Benefit Package

– Psychiatric Residential Treatment Facilities (PRTFs) (DMA Clinical Coverage Policy 8D1)

– Therapeutic Foster Care (TFC) (DMA Clinical Coverage Policy 8D2)

– Residential Child Care Levels II group, III, IV (DMA Clinical Coverage Policy 8D2)

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Excluded Services/Populations

• Early Intervention Services (0-2) are currently excluded– CDSA, including case management– CBRS– Outpatient MH services

• Very small #s of claims• FQHCs are excluded• Any BH service for children 3-5 are included

– INPT, OTPT, Enhanced, residential

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DMA Reporting- B Waiver• Use of Services

– Mental Health Utilization – Inpatient Discharges and Average Length of Stay*

– Mental Health Utilization – Percentage of Members Receiving Inpatient, Intermediate Care, Ambulatory and Other Support Services*

– Chemical Dependency Utilization – Inpatient Discharges and Average Length of Stay*

– Chemical Dependency Utilization - Percentage of Members Receiving Inpatient, Intermediate Care, Ambulatory and Other Support Services

– Integrated Care

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Where is Integrated Care?• 96150 and 96151 are billed by physicians directly to DMA

(provided incident-to by the BH provider)• All therapy codes (covered under 8x policies) are billed to the

LME-MCO• Contractual expectation that LME-MCOs support Integrated Care

by reporting Integrated Care efforts annually• Adjustments made to Clinical Coverage Policy 8C (no CCA for

brief interventions in primary care clinic)• Working through Provider Services to help with enrollment of

BH agencies as CCNC medical homes

***Be careful to still heed the rules – if you are a BH provider (LCSW, Psychiatrist, etc) you can only direct-bill the LME-MCO; non-physician BH provideres cannot be enrolled as a physician group.) 

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The Future: Partnership for a Healthy North Carolina

• Built based on over 160 responses to RFI• Improve behavioral and physical health care

outcomes• Build on gains and innovations in community-based

care and take it to the next level• *Look at each person as a whole, treating behavioral

and physical health needs in a collaborative way to improve the health of each individual.

http://www.ncdhhs.gov/medicaidreform/

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DMA

The Future: Partnership for a Healthy North Carolina

• Person-Centered –single entry point into system• Recipient CHOICE of 3-ish statewide Comprehensive

Care Entities that treats the whole person• CCE provides functional needs assessment at single

entry point• Comprehensive care focused on outcomes (backed

by strong contract)• Customer Service: simplified for providers and

patient-centered

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DMA

OnGoing Efforts

Get Involved!Get to know what can be billed and when; read and understand policy (we can help); know your value ($)

Give us Feedback!Systems are complex; let us know if something isn’t working or if you find something that could be improvedPeriodically policies go up for public review—feedback is carefully consideredhttp://www.ncdhhs.gov/dma/mpproposed/

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DMA

Medicaid/DMA Contacts

Courtney Cantrell, PhDAssistant Director for Behavioral [email protected]

http://www.ncdhhs.gov/dma/services/behavhealth.htmhttp://www.ncdhhs.gov/dma/lme/MHWaiver.htm