Managed Care and Behavioral Health – Crash Course Webinar Series
[Music] welcome to Epstein Becca green webinar manage care Behavioral Health part of Behavioral Health we’re pleased to have Epstein Becker greens Jackie sby who is a member of the healthcare and life sence practice in New York presenting today before we begin today’s presentation please be informed that today’s webinar is being recorded and the participant phone lines will be placed on mute throughout the program you are also welcome to submit questions directly to Jackie following the webinar and contact information will be displayed at the end of the presentation in approximately two to three business days following the webinar eping Becker green will communicate the availability of the webinar recording and access to the PowerPoint materials at this time I’d like to turn the webinar over to Jackie Thank you Lisa for the introduction and it is my pleasure to address managed care and Behavioral Health today the um overview of the presentation um first we’ll consider some background materials on managed care products and their regulation then um go over some Delivery Systems for Behavioral Health Care Services next I’ll address some key healthc care reform initiatives related to behavioral health and certain barriers or challenges to those reforms and then last some related developments in Medicaid and Behavioral Health since Medicaid is the largest pair of Behavioral Health Care Services in the country this slide shows some examples of managed care products most of which include Behavioral Health Services as a benefit the first tier is government products and includes Medicare advantage or Medicaid managed care and some duels products like f and paste or chip for children the second tier are exchange products offered by qualified Health Plans um whether federal or state exchanges and to individuals or groups and then the last tier commercial more traditional products like HMO or PPO offered to um fully insured or self-funded um individuals or groups these managed care products are offered by various types of Managed Care organizations or mcos I’ll call them for purposes of this presentation they can be hmos ppos QPS and other types of providers um note that the products as well as the mcos themselves are subject to different laws so this results in different legal analyses being required based on the specific product sector plan at issue um for example network access requirements um are different for Medicare Advantage versus Medicaid managed care and uh commercial fully insured versus um self-funded products the utilization management rules vary claims filing deadlines and prompt payment requirements vary for example most prompt pay laws don’t apply to self-funded business um denials and appeals processes can be different dispute resolution patient hold harmless obligations and confidentiality requirements can all vary now this is a really basic um diagram of a delivery system for managed care so the MCO would offer various products like some of the commercial or exchange or government products we just discussed and have agreements those lines would be agreements with different types of providers like Physicians hospitals or ancillary providers uh next slide so Behavioral Health Services however um could have a different delivery system they’re often carved out of a Managed Care organizations’s agreements with providers and they are then provided and managed separately by a specialized Behavioral Health Organization or a BHO which may or may not be affiliated with the MCO and those bhos often have their own network of providers with your own separate agreements um paid Behavioral Health claims and for those providers and perform utilization management or medical necessity review for those Services another example of a carved out service would be Pharmacy with pbms and the B’s likely have multiple MCO clients that access their networks and which makes the consistency of their contract terms with their Network um difficult and my point really is not only does applicable law vary by product and payer um but the contract terms also vary by product and pair and this is the same diagram just with the um carved out Behavioral Health Services delivery system added in so in green you’ll see the BHO um then has agreements with some of the same providers in this case provider b c and d um and the uh some of those providers have agreements with the mcos directly for the medical services some um there’s some overlap but not total overlap typically uh the next slide so you’ll see that providers who provide both medical and Behavioral Health Services for example the hospital and the prior diagram may have different agreements apply to services that they provide to the same individuals so if if they’re providing Medical Services to an individual one agreement applies if they’re providing Behavioral Health Services to that same individual a different agreement could apply now the terms of both such Agreements are likely to be different in some ways for example the policies and procedures might be different like clinical criteria used or prior authorization requirements for the services or even eligibility D verification for those individuals claims claim failing filing de lines may be different and of course reimbursement terms are likely to be different and um interestingly the term and termination Provisions um typically wouldn’t align um necessarily because like I said the MCO the bhos often have more than one MCO client and providers may end up actually being in network for medical services um but not in network for Behavioral Services for the same individual ual or population and vice versa I’ve I’ve had clients end up in that situation dispute resolution Provisions could be different um some offer you know arbitration versus litigation and um a unique challenge is often uh a unique challenge comes up when patients present with both medical and behavioral health conditions at the same visit um so it’s hard to know uh for the parties which agreement applies the diagnosis code for example can be medical um at admission but change to behavioral at discharge or vice versa um is actually not that uncommon and all of this can get of course confusing next slide now we’ll talk about some health reform initiatives related to behavioral health the first uh the first one is the Affordable Care Act mandates coverage of Behavioral Health Services as an essential health benefit and this is true for private plans and Medicaid plans and by Behavioral Health Services we mean U Mental Health Services and substance use disorder treatment the latter for most plans but not all and then next the Mia the mental health parody and addiction Equity act um essentially requires that behavioral health benefits be treated the same as medical benefits and Leslie young covered this last week in her webinar but um at a high level that means um Financial requirements like co-pay and deductibles are supposed to be the same quantitative treatment limits like visit limits should be the same and non-quantitative treatment limits like medical management and medical necessity review should be the same and then lastly there are um final mental health parity regulations for Medicaid and Chip du out tomorrow and they are expected to require parity regardless of the delivery system the goal is to create consistency between the commercial and the Medicaid Market markets other reforms include population health and value based payment and both of these types of reforms require coordination between the medical and the Behavioral Health Services for example acos whether Medicare or commercial and um Primary Care Medical homes um Medicaid expansion um in itself has resulted in increased provision of Behavioral Health Services the um expansion population has significant Behavioral Health needs there was an article uh today or yesterday in a North Carolina Paper since North Carolina is considering Medicaid expansion CMS is promoting um the benefits for behavioral health treatment if they do that expansion so um quoting from that uh article not o this is CMS um saying not only will more of these individuals be likely to receive treatment but this coverage expansion May reduce other medical costs increase employment productivity lower overall rates of depression and indirectly reduce criminal justice costs CMS also said that once one study of low-income adults for this population um showed that 50 30% I’m sorry had serious mental illness and are likely to receive uh treatment if they have Medicaid coverage um some states are still transitioning Medicaid um or the new Medicaid expansion population to manage care although 80% of all Medicade is now um under Managed Care some states however are going in the other direction for example Connecticut has moved man uh man Medicaid out of managed care and um some states even if they have managed care are in the process of carving in Behavioral Health to that managed care for the first time previously the state was p um for those Services directly although for example in New York even though the government’s carving it in so that um they’re paying Managed Care organizations for it then Managed Care organizations themselves can carve it out to another vendor and there are also increased numbers of State Medicaid waiver and demonstration projects as of September 2015 there were 55 approved section 1115 demonstration products and 18 different States many of which involve Behavioral Health Services and lastly um there is definitely an increase in federal level regulation of Medicaid Managed Care um for example CMS proposed a broad-reaching rule last May that seeks to align Medicaid managed care with commercial Medicare Managed Care markets um so there are some unique challenges related to such Health reform initiatives two um Hallmarks of health health care reform which are care coordination and the integration of Behavioral Health Care with primary care are proving more challenging for various reasons um including the fragmented regulation and Delivery Systems confidentiality requirements being more stringent for Behavioral Health and Trish Wagner covered this in her webinar two weeks ago another level of coordination is required um to integrate mental health and substance use disorder since they’ve historically been regulated differently and um measuring quality improvement and cost savings for purposes of value based payment initiatives are uh more difficult for the same reasons lastly compliance with the mental health parity law is proving challenging for pretty much the same reasons now switching just to Medicaid um specifically as I mentioned it’s the largest single pay for mental health services in the US and it increasingly plays a larger role in reimbursement for substance use disorders um given the Medicaid expansion population here’s some data with respect to um Medicaid spends um for enroles with Behavioral Health diagnosis but it’s back from 2011 I I haven’t seen more recent data I think for in the interest of time I’ll skip this the rest of this slide but on the next slide it’s really the bottom line that um total Medicaid spending per enrol e is almost four times as much for enroles with a behavioral health diagnosis than for those without a behavioral health diagnosis um so the next slide please given all this um many states have ongoing pilots and initiatives to improve access to behavioral health and improve quality and reduce cost of Behavioral Health Services and taking New York as an example because um approximately one third of the the state um New Yorkers have Medicaid as their health care um Benefit Plan and New York has multiple Medicaid Managed Care projects involving Behavioral Health Services taking place right now one is disrup which stands for delivery system reform incentive payment and that includes approximately 8 billion doll over five years in federal incentive payments for providers to organize and um take on projects many of uh some of which I should say include integrating Primary Care with Behavioral Health there have been about 25 of those provider systems in the program it’s uh just passing one year and the um there’s another product called harp health and Recovery plans in New York for severely mentally or substance use disorder patients as of last October and this offers Home and Community Based Services to address uh social and non-healthcare related challenges that accompany behavioral health issues and finally New York is also planning an ID fup product for the intellectual and developmentally disabled population and I think with that it brings me to the end of the 15 minutes so thank you for your time today and please don’t hesitate to contact me if you have any follow-up questions thank you very much thank you Jackie this concludes today’s webinar we have a reschedule of a behavioral health crash course webinar investments in Behavioral Health drivers and Outlook it’s scheduled for next Tuesday at April 5th um if you have not yet registered please feel free to do so information will be sent out today in approximately 2 to three business days following this webinar we will communicate the availability of the webinar recording and access to the PowerPoint materials thank you for attending
Epstein Becker Green Webinar, with Attorney Jackie Selby – March 29, 2016
This webinar series should be of interest to providers, payors, private equity investors, and other health care and mental health stakeholders.
This webinar will provide:
* An overview of the unique contract issues related to behavioral health services
* Reforms in Medicaid managed care plans and behavioral health
http://www.ebglaw.com/events/managed-care-and-behavioral-health-behavioral-health-crash-course-webinar-series/
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