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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.

House Republican per-capita cap proposal for Medicaid would decrease funding, increase number of uninsured

Posted in Affordable Care Act, Health Care Reform, Medicaid

A new report from Loren Anthes at The Center for Community Solutions outlines the potential for Ohio’s Medicaid program to lose between $19 to $26 billion between 2019 and 2025 because of the House Republican’s proposed health reform legislation (the American Health Care Act); these predictions closely align with the new Congressional Budget Office (CBO) analysis of the same bill.

As mentioned in a recent Vorys Health Care Advisors blog post, the House Republican Plan would fundamentally change Medicaid’s financing structure from a federally-matched entitlement to a per-capita cap program that would include some funding for states to continue Medicaid expansion (Group VIII enrollment) for a few years.  According The Center for Community Solutions report, this change would leave Ohio policymakers with tough decisions regarding funding for all individuals receiving Medicaid in the state:

  • “Ohio would need to contribute or cut $7.2 – $9.5 billion in state funding through 2025 to maintain projected funding levels for the entire program, with specific population funding changes as follows:
    • Children: Shortfall of $2 – 2.3 billion
    • Adults: Shortfall of $3 – 4.3 billion
    • Disabled: Shortfall of $2.2 – 2.7 billion
    • Aged: Surplus of $1.9 billion
    • Group VIII: Shortfall of $1.7 – 2.1 billion
  • It is unclear if a per capita model would conflict with standards of actuarial soundness, potentially compromising the ability for Ohio to have a privatized delivery system through managed care.”

As widely reported today, the CBO report predicts that the American Health Care Act would cause 14 million fewer individuals to have health insurance in 2018 across the United States, in large part because of the proposal’s repeal of the penalties associated with the Affordable Care Act’s individual mandate.  Moreover, the CBO predicts insurance losses would dramatically increase after 2018 because of changes in Medicaid financing:

“Later, following additional changes to subsidies for insurance purchased in the nongroup market and to the Medicaid program, the increase in the number of uninsured people relative to the number under current law would rise to 21 million in 2020 and then to 24 million in 2026. The reductions in insurance coverage between 2018 and 2026 would stem in large part from changes in Medicaid enrollment—because some states would discontinue their expansion of eligibility, some states that would have expanded eligibility in the future would choose not to do so, and per-enrollee spending in the program would be capped. In 2026, an estimated 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.”

The CBO report goes on to state that the proposal would produce “a reduction of $880 billion in federal outlays for Medicaid.”  According to the Center on Budget and Policy Priorities, this considerable cut in federal funding would directly shift Medicaid costs to states, undoubtedly forcing states to to end or limit Medicaid expansion while simultaneously decreasing access and benefits for other (non-expansion) enrolled individuals.

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Vorys Client Alert: A summary of the Republican House plan to replace the Affordable Care Act

Posted in Affordable Care Act, Health Care Reform

On March 6, 2017, House Republicans released proposed legislation  to repeal and replace the Patient Protection and Affordable Care Act (ACA). Vorys attorneys Matthew E. Albers, Jennifer Bibart Dunsizer, Linda R. Mendel, Christine M. Poth and Nita Garg summarize the proposal on the Vorys Website.


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House Republican health plan would shift estimated $560B in Medicaid costs to states, impact all Medicaid enrollees

Posted in Access, Affordable Care Act, Behavioral Health, Health Care Reform, Medicaid

The House Republican plan to reform Medicaid projects federal savings of more than $500 billion dollars over 10 years, and the Center on Budget and Policy Priorities, a nonpartisan research and policy institute, estimates this plan would significantly shift Medicaid costs directly to states, “effectively ending the Affordable Care Act’s (ACA) Medicaid expansion for 11 million people while also harming tens of millions of additional seniors, people with disabilities, and children and parents who rely on Medicaid today.”

It is reasonable to argue that a 90% federal match for the expansion population is too much of a federal contribution to be sustained for the long run and states need to have ‘more skin in the game’. However, the effect of the House proposal would be a massive cost shift to states for the entire Medicaid program, guaranteeing that consumers’ access to care will suffer.

There are two Ohioans worth mentioning who will be effected by this cost shift. First, there is Dave. He’s about 48 years old and has a serious addiction. He is one of the 700,000 Ohioans who received coverage through Ohio’s Medicaid expansion; finally able to get treatment for his addiction.  His physical health has improved and he’s been able to work more steadily, but recovering from his addiction will take some time. He’s on the path to recovery. Ohio’s assessment of the expansion shows there are many Ohioans like Dave – people who were uninsured and gained access to health care that not only improved their physical and mental well being, but also made it easier for them to work and seek work and to improve their personal financial situations. Dave may not continue to have Medicaid coverage if funding for the Medicaid expansion populations is decreased and eventually eliminated.

Second, there is Molly. She is 33, has Down’s Syndrome, and receives a Medicaid home and community based waiver that allows her to share a house, work her job at the coffee shop, and enjoy her life in the community. She is one of the roughly 90,000 Ohioans who are elderly and/or disabled who receive home and community services, representing a small number of people enrolled in the Medicaid program, but accounting for a high proportion of overall Medicaid costs. Molly and other non-expansion individuals are not included in the House’s proposed cuts to Medicaid expansion, but will still be affected by the proposal’s shift in how the entire Medicaid program would be funded. The Center on Budget and Policy Priorities analysis estimates that overall, the house draft bill “would cut federal spending for the Medicaid program by an additional $280 billion over the next decade” on top of the proposed cuts to eliminate Medicaid expansion. These cuts would occur because of the plan’s intention to move Medicaid away from an entitlement program and into a per-capita cap system, which would account for neither the costs for community services (like those being used by Molly) rising at more than the rate of inflation, nor the cost of other significant health events Molly and Medicaid-enrolled individuals may encounter as they grow older.

Let’s not lose sight of the impact on Dave and Molly as the debate in Congress continues.

See the full analysis at the Center on Budget and Polity Priorities Blog.

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Multi-System Youth: Update, Ohio Budget Activity

Posted in Medicaid, multi-system youth, Presentations

Stakeholders and legislators continue to advocate to improve service capacity and delivery for youth served by multiple child-serving systems in Ohio. In strong partnership with the Public Children Services Association of Ohio (PCSAO), a number of legislators created the Joint Legislative Committee on Multi-System Youth through Ohio’s last biennial budget (H.B. 64 of the 131st General Assembly) to study  issues affecting multi-system youth, including custody relinquishment.  Please see our original post on the charges of this Committee, which was Co-Chaired by Senator Randy Gardner and Representative Sarah LaTourette.

Last summer, after holding seven hearings and receiving testimony from youth and their families, service providers, State Agency officials, and policy experts, the Committee released a list of recommendations to address the needs of multi-system youth and their families.  Briefly, the recommendations ask relevant State Agencies to:

  1. Establish a state-level crisis stabilization fund to address unmet and uninsured needs of Ohio’s multi-system youth and families who are in crisis and/or unable to access appropriate levels of care and services.
  2. Design a Medicaid-reimbursable service consistent with High-Fidelity Wraparound principles to coordinate the care, services, and supports that youth and their families need.
  3. Establish a unified strategy for data collection and sharing across child serving systems to identify resource utilization, service utilization patterns and gaps, and monitor outcomes.
  4. Develop youth and family focused peer support services.
  5. Modernize Ohio’s Family and Children First Councils.
  6. Fund an independent evaluation of timely access to children’s and youth’s residential and inpatient mental health treatment in the State of Ohio.

Now, almost a year after the Legislative Committee held its first hearing, Senator Gardner, Representative LaTourette, and a robust group of stakeholders are working to implement the recommendations above through Ohio’s next biennial budget.  The list of multi-system budget requests closely follows the recommendations of the Committee, and it includes both funding and policy items that could be included in Ohio’s budget for State Fiscal Years 2018-2019. Stakeholders will continue to work closely with Senator Gardner and Representative LaTourette, state agencies, and the public to make sure these issues and recommendations are priorities throughout the entire budget process.

On January 30, 2017, Maureen Corcoran and Marisa Weisel of Vorys Health Care Advisors and Gayle Channing Tenenbaum of The Center for Community Solutions presented about multi-system youth to the Attorney General’s Task Force on Criminal Justice and Mental Health. This Task Force, co-chaired by Attorney General Mike DeWine and Justice Evelyn Lundberg Stratton, Retired, and Of Counsel at Vorys, met to discuss criminal justice and mental health issues affecting Ohio’s children and youth. The audience was composed of individuals who work in the fields of criminal justice and/or mental health, both inside and outside of state government. This passionate group demonstrated a deep understanding of children who receive services form multiple systems, and many expressed appreciation for the work being done to bring attention and potential solutions to the challenges facing multi-system youth and their families.

New Report Regarding Drug Purchasing in Ohio

Posted in Access, Drug Pricing, Health Care, Medicaid, Pharmaceuticals

A proposed initiated statute to change state prescription drug purchasing in Ohio would be difficult if not impossible to implement, according to a new report issued by Ohio public health policy experts.

The report, released today from Vorys Health Care Advisors (VHCA) and Health Management Associates (HMA), analyzes the proposed initiated statute to change state prescription drug purchasing in Ohio. The research team was led by VHCA President Maureen Corcoran and Barbara Coulter Edwards, Managing Principal with HMA, both well-known in the health care field with extensive experience in Medicaid.  The report includes data and information gathered from state agencies likely to be impacted by the proposal.  The independent analysis was commissioned by the Pharmaceutical Research and Manufacturers of America.

“There would be little to nothing to be gained under the Act,” said Corcoran. “Instead the state could see increased costs in administrative functions in an effort to comply, while at the same time losing valuable supplemental rebate arrangements currently in place with drug manufacturers.”

The proposed initiated statute seeks to prohibit the state from entering into contracts where the “net cost” of a prescription drug purchased by the state is more than the “lowest price paid” by the U.S. Department of Veterans Affairs (VA).

If adopted, the proposed statute would affect roughly 4 million Ohioans. In addition to Ohio Medicaid, the state retirement systems and certain programs operated by state departments, the report also describes potential negative impacts on entities outside of state government, e.g. state universities and community colleges, the RxOC purchasing collaborative, BestRx, and concerns about access to VA-administered drugs now available to military veterans.

The Act would not apply to the approximately seven million Ohioans who use private insurance or other coverage.

The report concludes that:

  • It is highly unlikely the proposed statute could be implemented.
  • It is highly likely the proposed statute would fail to achieve its purpose.
  • It is highly likely that pharmacy programs of entities outside of state government would be negatively impacted.
  • State agencies would need to take other extreme measures in an attempt to comply with the mandate, which could result in higher copays, decreased access to community pharmacies, or even limits on available drugs for impacted individuals.

Click here to download the full report.

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 https://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.