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Vorys Health Care Advisors

For health care reformers, the challenge is to improve care quality and expand access to providers and services while controlling costs. It is not a job for the timid. Instead, it requires creativity, experience and leadership. Vorys Health Care Advisors’ strategic solutions and guidance exemplify each of these imperatives. Our health care and Medicaid consultants help providers, business decision makers, state and federal government agencies and professional associations respond to the complex needs of health care consumers by discovering, developing and implementing innovative policies and programs.

Date Nears for States to Implement CMS Access Rule

Posted in Access, CMS, Health Care, Medicaid, Regulations

On January 4, 2016, the Center for Medicare and Medicaid Services (CMS) implemented sweeping new requirements for ensuring access to specific categories of Medicaid services. The final rule, released on November 2, 2015, and titled Medicaid Program; Methods for Assuring Access to Covered Medicaid Services, creates a very important vehicle for beneficiaries, service providers, their associations and advocacy organizations to have meaningful input in the construct of states’ fee-for-service Medicaid payment methodologies.  Per the final rule, states must submit initial access review plans, including stakeholder feedback, to CMS by July 1, 2016.

The new regulation requires states to demonstrate compliance with the statutory requirement that Medicaid payments are sufficient to enlist enough providers to ensure access to covered services for beneficiaries is equivalent to that of the general population.  This access requirement applies to fee-for-service payments and does not apply to managed care, waiver, or demonstration program payments.

The new regulation mandates baseline and follow-up reviews of access to core services in the areas of:

  • Primary care (physician, federally qualified health center, clinic, dental);
  • Specialty physician;
  • Mental health and substance use;
  • Obstetrics (prenatal, labor and delivery, postpartum); and
  • Home health.

Additional mandatory reviews are triggered when:

  • Payments are reduced or restructured;
  • New services are implemented; and
  • High levels of access complaints are received.

Further, access reviews must:

  • Describe the population including considerations for its care, service utilization, and payments, for adults, children and individuals with disabilities;
  • Measure whether beneficiary needs are fully met;
  • Document the providers reviewed are enrolled with Medicaid; and
  • Demonstrate access to care within a specific geographic area.

States must issue the initial access monitoring review plan by July 1st of 2016 and submit an update of a subset of service categories by July 1st every three years thereafter.  The plan must be developed in consultation with the state’s medical care advisory committee and the data analysis and supporting documentation made available for public review and comment at least 30 days prior to its submittal to CMS.

When an access deficiency is identified, states are required to develop and submit a corrective plan to CMS within 90 days and must remediate the deficiency within 12 months.  States that fail to take remedial action risk the loss of federal financial participation.  To correct access issues, CMS suggests states can:

  • Increase payments;
  • Improve provider outreach, enrollment, and retention;
  • Enhance transportation;
  • Improve care coordination; and/or
  • Modify provider licensing and scope of practice policies.

In deference to unique state circumstances and in the interest of granting flexibility, CMS did not promulgate a specific format for the access review plans.  Some data elements will be mandatory, however, including a comparison of Medicaid payments to other public and private insurance payments, by provider type and site of service.  Suggested data elements include:

  • Time and distance standards;
  • Providers participating in the Medicaid program;
  • Providers with open panels;
  • Providers accepting new Medicaid patients;
  • Service utilization patterns;
  • Identified beneficiary needs; and
  • Logs of beneficiary and provider feedback.

CMS expects states to solicit stakeholder input during development of the access and remedial action plans as well as on an ongoing basis.  States are required to establish a mechanism – surveys, ombudsman, or equivalent – to receive input from stakeholders and to log the volume and nature of this input and their responses to it.  CMS will rely on this mechanism to understand access to care concerns and may, as a result, require states to monitor additional services.   States are required to investigate, analyze and respond promptly to public input.  Should stakeholder concerns not be adequately addressed by the state, they may be raised with CMS directly.

As previously noted, states must submit their initial access monitoring review plans to CMS by July 1, 2016.  As part of this process, draft plans must be available for review and public comment at least 30 days prior to being finalized and submitted to CMS, and draft plans are expected within the next two to three months.  Advocates, providers, and provider associations will want to become familiar with the access rule as they prepare to engage in the stakeholder input and public comment processes.  On March 16, 2016, CMS posted a Frequently Asked Questions (FAQs) document about implementing the access rule that addresses both stakeholder input and public comment.


New on the HealtHITech Law Blog: proposed updates to federal confidentiality of alcohol and drug abuse patient records Regulations

Posted in Behavioral Health, privacy, Regulations, SAMHSA

As reported by Vorys attorney J. Liam Gruz on the HealtHITech Law Blog, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) recently published a proposed rule which would amend the Confidentiality of Alcohol and Drug Abuse Patient Records regulations, found in 42 C.F.R. Part 2.

SAMHSA’s long awaited proposed rule seeks to modernize the confidentiality provisions to better reflect the current treatment system, particularly with respect to ease of transferring records and patient information, while still maintaining privacy protections for those receiving substance use treatment.

Read the entire post at the HealtHITech Law Blog.

Multi-system youth: the need for additional and coordinated services

Posted in Behavioral Health, Care Coordination, Child protection, Medicaid, multi-system youth, Wrap-around

2/3/2017: Please see our latest post on multi-system youth at http://www.voryshcadvisors.com/2017/02/03/multi-system-youth-update/ 

“Multi-system” youth are children and adolescents served by multiple public systems, including state agencies providing both financing and direct services in the areas of:

  • Child protection,
  • Health care (often through Medicaid),
  • Juvenile justice,
  • Intellectual and developmental disabilities,
  • Behavioral health care (both mental health and addiction services),
  • Child care, and
  • Education.

Multi-system youth have complex needs that cannot be met by a single system. In some cases, two or more systems are used to fill gaps in services offered single agencies or when the cost of providing services becomes prohibitive for a single agency.

Most states make efforts to coordinate services for youth across systems and agencies. In Ohio, the Family and Children First Council was created in 1993 to “cluster” together members of local child caring agencies. For more than two decades, Local Family and Children First Councils (FCFCs) have streamlined and coordinated existing services for families seeking assistance by considering the best and most appropriate care for a child with needs from two or agencies. In 2014, local FCFCs provided service coordination for 5,491 youth, including 287 multi-system children who required specific types of residential and out of home treatment.

While local support and collaboration have been successful in helping many children and their families, some youth served by multiple systems have needs so extreme that they cannot be supported through this method alone. Often, when children have intensive needs that exhaust the resources of both the family and community, parents are forced to relinquish custody to a child protection agency to access necessary services. Nationally, more than 12,700 children were relinquished into the custody of the state to gain access to mental health services. According to a recent policy brief on multi-system youth from the Public Children Services Association of Ohio,  nearly one in three (30%) of multi-system youth in Ohio entered public children services agency via custody relinquishment. As the following chart from the PCSAO policy brief shows, custody relinquishment occurs for a large fraction of youth served by the juvenile justice, developmental disabilities, and behavioral health systems in Ohio.

PCSAO Survey - Multi-System Youth via Custody Relinquishment

In recognition of the issues affecting multi-system youth, Ohio’s most recent state budget created the Joint Legislative Committee on Multi-System Youth to:

  • Identify the services currently provided to multi-system youths and the costs and outcomes of those services;
  • Identify existing best practices to eliminate custody relinquishment as a means of gaining access to services for multi-system youths;
  • Identify the best methods for person-centered care coordination related to behavioral health, developmental disabilities, juvenile justice, and employment;
  • Identify a system of accountability to monitor the progress of multi-system youths in residential placement; and
  • Recommend an equitable, adequate, sustainable funding and service delivery system to meet the needs of all multi-system youths.

The Joint Committee held its first hearing on January 19, where it named Senator Randy Gardner its Chair and Representative Sarah LaTourette its Vice-Chair. The Committee’s second hearing, held February 16, 2016, featured a panel of young adults shared personal experience being involved with more than one state agency. The youth highlighted the need for additional services and supports for multi-system youth and their families, including for wrap-around services, peer-to-peer support, in-home support for parents, greater supports for adopted youth and their parents, and other measures to the state could implement to create a more cohesive experience for children who need services from multiple systems.

Mary Wachtel, Legislative Director at PCSAO, testified that, “the reality is that parents and families are still faced with very difficult decisions about how to get their children the help they need.  Some folks have to consider actually relinquishing custody in order to gain services for their children; others have to balance how to keep a child at home and keep other family members safe. And for too many families, they still are facing these decisions.”

Four young adults testified in a panel before the Committee. Rafael Weston, Rebecca McGovern and Braxton Devault gave testimony about their lives and experiences with systems of care that aim to address mental health, medication and addiction, human trafficking, and abuse. Overall, the youth shared messages that were personal and powerful as they talked about the following:

  • Feeling connected to peers with similar experiences reduced his feeling of isolation;
  • Having had help with parenting, which has helped to overcome challenges with addiction;
  • Positive experiences in a transitional age youth program for those between the ages of 18-22 provides basic independent living skills;
  • Youth advocacy as an important counterbalance to negative messages;
  • Caution that should be taken against overprescribing medications;
  • The experience of human trafficking;
  • Early education to avoid drug use is important; and
  • Ways in which  Youth M.O.V.E. (Motivating Others Through Voices Of Experience) can be helpful as to grow youth leadership and provide a powerful voice of experience.

The youth mentioned a number of ways they could have been better served, including:

  • Support specifically for adopted youth and their adoptive families when struggling with behavioral health issues;
  • Cohesive communicative services that connect between systems of care;
  • The creation of a wellness plan;
  • Preventing abuse through early intervention and in-home supports;
  • More support for parents to prevent removal from the home; and
  • Services offered closer to home so youth and their families can avoid traveling to other counties to access care.

The legislators asked probing and compassionate questions.  The youths’ own words best describe their experiences.

Weston shared his story of being the youngest of three boys to a single mother.  He said had problems with reading, but was also diagnosed with other behavioral issues and had a negative image of himself because adults would ask what was “wrong” with him. That negativity also played out when his mother couldn’t retain custody of him because she lacked financial resources, and he thought his mother gave him up for adoption. He also said that the residential facility he was in was like “another form of prison” with the possibility of having his possessions stolen or getting hurt.

McGovern, who was the victim of human trafficking, took issue with being returned to her adoptive parents that abused her and said adopted youth who have behavioral health needs would greatly benefit from additional supports.

A number of the panelists told members of the Committee about the benefits of wrap-around services. McGovern, who attends weekly meetings with a drug and alcohol counselor, said having a case manager and a psychiatrist on her team allowed her to focus specifically on addiction issues at group meetings. She said she also benefits from parenting help through the city’s Healthy Moms and Babes program. Weston said he would have benefited from a residential facility that would have created a wrap-around type of plan specifically for him.

The panelists also noted the importance of positive peer supports and mentors. Devault said Youth M.O.V.E. and another autism-oriented program allowed him to connect with peers who have had similar experiences, and Weston agreed Youth M.O.V.E. made him feel less isolated. Weston also said youth advocacy is important for high-risk children because they receive negative messages about themselves and giving them opportunities, to speak to lawmakers, for example, helps put positive labels on themselves.

“A lot of times I really just needed a positive, friendly role model so I didn’t feel so alone,” Devault said.  When questioned about an appropriate age for young people to start interacting with peers who have faced similar experiences, Weston said kids need to be engaged socially “as young as possible.”

Chair Gardner expressed hope that stakeholders could provide the Committee with metrics on the possible “unevenness” of state services across counties, especially for transition age youth.

In hearing from youth served by multiple systems, the Committee has already made great progress. We look forward to the Committee’s continued work as it begins to craft solutions that address the complex needs of children served by multiple systems, particularly those who are voluntarily relinquished into the custody of child protection to gain access to services.

CMS Final Rule on Reporting Overpayments

Posted in CMS, Health Care, Overpayments, Regulations

Yesterday, the Centers for Medicare and Medicaid Services (CMS) published a final rule regarding health care providers’ duty to report and return self-identified Medicare Part A and Medicare Part B overpayments to CMS.  The purpose of this final rule is to provide clarification of the meaning of overpayment identification and the required look-back period for identifying overpayments.  These clarifications significantly impact the ability of health care providers to avoid federal False Claims Act (FCA) liability.

For more information about the final rule, please see the client alert written by Vorys attorneys Victor A. Walton, Jr. and Jacob D. Mahle.

2016-02-11 client alert

Ohio’s Behavioral Health Redesign – Part 1

Posted in Behavioral Health, Managed Care, Medicaid, Physical and Behavioral Health Integration

Ohio’s behavioral health service delivery and payment systems are heading in a new direction. Over the next three years, we expect providers and service recipients to experience significant changes as alterations are made to the state’s determination of eligibility, authorized providers, covered services, and payment amounts and methods. This is the first post of a four-part series that will provide an overview of the coming changes and more detailed discussions of three separate but related areas of the redesign over the coming weeks:

  • New disability determination and a new 1915(i) state plan benefit;
  • Redefining existing services to align with national coding standards; and
  • Moving behavioral health into managed care.

The following paragraphs provide a “big picture” overview of each redesign area.

Disability determination changes and the 1915(i) amendment

The recent passage of Ohio’s 2016-2017 biennial budget (H.B. 64) has enabled Ohio to pursue a variety of eligibility changes, with the goal of streamlining eligibility determination processes. One important component of the changes, the elimination of the ‘spenddown’ process, will impact some adults with serious mental illness. With creative use of a little-used Medicaid option, which is targeted to go into effect in July 2016, the state is working to maintain eligibility for affected individuals. To assure continued essential to community based services within this population, the state is pursuing a new Medicaid 1915(i) state plan amendment that would provide eligibility to an estimated 5,000 people. The Ohio Department of Medicaid intends to submit the 1915(i) state plan amendment to the Centers for Medicare and Medicaid Services (CMS) before the end of this year. The planned changes to disability determinations and the 1915(i) amendment will be explored in the next post.

Redefining existing services to align with national coding standards

The current menu of behavioral health services available in Ohio has changed very little in more than 15 years and has not kept up with current medical coding conventions. Services such as community psychiatric supportive treatment (CPST), pharmacologic management, substance abuse disorder, medical/somatic, and others are being reviewed for redesign. In the future, providers will need to use industry-standard codes to bill instead of using the codes in place today that are unique to the state. Ohio will also begin using National Correct Coding Initiative (NCCI) edits to standardize payment logic as part of this process. Along with these changes, the state plans to provide coverage for new behavioral health services as part of the redesign process; these may include services such as assertive community treatment, intensive home based treatment, high fidelity wrap around, peer services, supportive employment, and residential substance abuse disorder treatment. The third post in this series will provide greater detail about these coding and service changes, which are currently being discussed in state-led workgroups. July 2016 is the target date for implementing the new service menu.

Implementing managed care for community behavioral health services

Prior to the adoption of H.B.64, Ohio statute precluded alcohol, drug addiction, and mental health services covered by Medicaid from being included in a managed care system, which meant these services were available on a fee-for-service basis. As enacted, the budget bill removed this exclusion.  After extensive legislative discussion during the budget process, a modest change was made to the originally proposed timeframes for implementing managed care for behavioral health services. The work to redesign the service menu, as described above, is an essential foundation for transitioning into managed care. Ohio is moving aggressively to prepare for this change over the next twenty eight months, with a target implementation date of January 2018. The fourth blog post in this series will discuss implementing managed care systems for behavioral health services.

Concluding thoughts

The provision of behavioral health services in Ohio will be radically transformed over the next few years. Instead of the current system, which allows any provider who is willing to provide services to receive fee schedule payment amounts for historically familiar services, select panel providers will negotiate with the managed care plans operating in their service area to provide newly defined services. All health care providers – particularly those providing behavioral health services – will need to clearly understand the operational and financial implications of these changes. Please stay tuned as our blog dives into the details of these important topics over the coming weeks.

VHCA Webinar on New Medicaid Managed Care Rules

Posted in Behavioral Health, CMS, Health Care, Managed Care, Medicaid, Regulations

CMS recently proposed regulations regarding Medicaid managed care.  The proposed rule, which was released on June 1, offers the fist major update to Medicaid and CHIP managed care regulations since 2002 – in many ways, this update and modernization of the regulations is overdue.  In general, the proposal takes a big step toward aligning Medicaid and CHIP managed care requirements with those already in place for qualified health plans (marketplace plans) and Medicare advantage plans.  The proposed regulations also:

  • Establish standards for plan network adequacy
  • Create new beneficiary protections, especially for vulnerable populations
  • Establish a medical loss ratio (MLR) for plans
  • Require greater transparency in capitation rate setting
  • Create a new framework for quality improvement
  • Change the way in which plans can pay for short-term stay in institutions for mental disease (IMDs)
  • Give states flexibility in designing and administering managed long term services and supports (LTSS)
  • Provide opportunities for states and plans to work together toward innovative payment and delivery reforms

Earlier this month, Vorys Health Care Advisors President Maureen M. Corcoran and Vorys health care Partner Suzanne J. Scrutton co-hosted a well-attended webinar about key provisions of the proposed regulations.  The webinar focused on the following areas of interest:

  • What and who is covered by the rule
  • Financial considerations
  • Implications for access and quality of services
  • Key regulatory issues

Webinar attendees included a wide variety of health care professionals working in the areas of behavioral health, developmental disabilities, children with special needs, and long-term services and support.

A full copy of the webinar slides is available for download.  Questions and comments about the webinar and its content can still be submitted to Maureen at MMCorcoran@VorysHCAdvisors.com and to Suzanne at SJScrutton@Vorys.com.


Governor Kasich Proposes Numerous Tax Changes in 2016-2017 State Budget

Posted in Articles, Health Care

Ohio Governor John Kasich recently outlined the tax changes he will include in his 2016-2017 biennial state budget.  The governor’s proposal is a mixture of cuts, increases and elimination of taxes which he says will result in a net $500 million tax cut for Ohioans. The taxes included in his package are: sales tax, commercial activity tax, oil and gas severance tax, individual income tax and tobacco tax.

No language has been introduced in bill form so the details of these proposals remain unclear. Hearings on the governor’s budget began February 3 in the Ohio House and will continue through mid-April. More details about the tax proposal will come out during these hearings as Tax Commissioner Joe Testa and other cabinet officials testify. The administration will also release more detailed information in the next few weeks.

To learn more about the tax proposals, read this Vorys State and Local Tax Alert.

Court Ruling On Companionship Services Exemption

Posted in Medicaid

Recent federal court action ensuring that employers may continue to take advantage of minimum wage and overtime exemptions for companionship services protects providers of home and community-based services (HCBS), at least for the time being. As this Vorys, Sater, Seymour and Pease health care alert indicates, the ruling means that employers of direct care workers may continue to take advantage of minimum wage and overtime exemptions for companionship services as they have in the past. This is important to the stability of the provision of HCBS under states’ Medicaid HCBS waivers.

Ohio Receives $75 Million State Innovation Model Grant from CMS

Posted in Medicaid, Uncategorized

The State of Ohio has earned a $75 million implementation grant to continue work already underway to reform health care delivery and payment.

The Centers for Medicare & Medicaid Services (CMS) announced earlier this week state recipients of second round funding for payment and system reform initiatives. Ohio is included in the list of winners, with a $75 million implementation grant to continue funding its State Innovation Model (SIM) focused on widespread use of patient centered medical homes, as well as implementation and expansion of episode based payments.

Round two funding provides more than $665 million to support state-led, multi-payer health care payment and service delivery models that will improve health system performance, increase quality of care, and decrease costs for payers and consumers. The Governor’s Office of Health Transformation envisions rollout of its SIM as follows:

Additional information on State Innovation Model initiatives can be found on this link.

Corcoran Participates in Cincinnati Edition Panel on Health Insurance Marketplace Open Enrollment

Posted in Affordable Care Act, Medicaid, Presentations

Maureen Corcoran, President of Vorys Health Care Advisors, participated on Monday’s live Cincinnati Edition panel on 91.7, WVXU in Cincinnati.  Maureen and Cara Stewart, Health Law fellow with the Kentucky Equal Justice Center, and Kathryn Keller, Interact for Health Vice President for Policy and External Relations, spent nearly 40 minutes discussing with host Mark Heyne the experience of individuals who enrolled in Marketplace health insurance plans in 2014 and how the open enrollment period for 2015 (beginning in November) promises to be an improved experience.  The panel also discussed Ohio’s and Kentucky’s experiences with enrollment in health insurance, including Medicaid expansion.

Listen to the panel’s discussion.