Managed Care

In October 2012, the Medicaid Redesign Team (MRT) and the MRT Behavioral Health Workgroup put forward a number of recommendations (MRT Behavioral Health Workgroup Final Recommendations) to support the careful and responsible transformation of the current fee-for-service system to Medicaid Managed Care for Medicaid enrolled individuals with Substance Use Disorder (SUD) and Mental Health (MH) treatment needs.

In order to ensure that the transformation of the behavioral health system has a positive and lasting impact on the behavioral health population, New York sought input from all stakeholders.  The input received will be used to draft a Request for Qualification that will be sent to managed care plans as well as guide NYS in the provision of Plan and Provider readiness assistance.  Behavioral Health Transition to Managed Care

On February 26, the Behavioral Health MRT met to review the status of the Phase I BHOs, the timeline for transition to managed care, and the comments/themes received for the RFQ process.  Presentations from the meeting are here.

The New York State Council has presented several programs for the membership to help prepare them for the transition to full managed care.  Members can access these presentations under the Archived Events section of this web site.

In addition, the NYS DOH regularly provides webinars to update the public on the status of the behavioral health transition to managed care.  Their latest presentations are here:

Updates:

October 9, 2015 : Managed Care Update 2

This has been a busy time as we complete our first full week of the new managed care services in New York City.  The good news is that all the hard work by providers, plans and government partners created a fairly smooth transition for most consumers.  That said, everyone has been hard at work dealing with the associated growing pains.

In this update we want to share some items of interest to the field.  You may have seen some of this in other emails. This update puts it all in one place and reaches those who may not have gotten it previously.

  • OMH and OASAS have both received requests for a listing of the HARP plans names associated with the Mainstream plan name.  The chart below reflects this listing.  Also indicated in the chart is a new change for the plan formerly known as Amerigroup

Plan Name

HARP Product Name

NYC Designation Status

Empire Blue Cross Blue Shield HealthPlus (Formerly HealthPlus Amerigroup)

Empire Blue Cross Blue Shield HealthPlus

HARP

HEALTH FIRST PHSP INC

HealthFirst Personal Wellness Plan

HARP

Health Insurance Plan of Greater New York (EMBLEM)

EmblemHealth Enhanced Care Plus

HARP

METROPLUS PARTNERSHIP CARE SN

MetroPlus Enhanced

HIV/SNP
HARP

NYS CATHOLIC HEALTH PLAN INC (FIDELIS CARE)

HealthierLife

HARP

UNITED HEALTHCARE OF NY INC

UnitedHealthcare Community Plan-Wellness4Me

HARP

  •  The topic of utilization management is high on many people’s agenda.  This week OMH issued a clarification to Mental Health Clinic providers regarding managed care plan provisions for clinics related to 90 day continuity of care provisions and the 30 visits concurrent review. provisions in the managed care plan.  A copy of the memo is attached.
  • As consumers move to services under the managed care plans there will be period of time when the old fee-for-service system and the new system are both operating.  This .creates challenges for billing departments.  In an effort to assist them, OMH and OASAS issued billing guidance for the inclusion of behavioral health services in the Medicaid managed care benefit package.  MCA copy of that memo is attached for further information.
  • To help with communication we have set up a new mailbox for your Managed Care questions.  To ensure that responses to all questions related to this transition are coordinated, and to help us assemble a list frequently asked questions (FAQs), we are asking that OMH Providers use the attached form for submitting questions, issues and/or concerns to OMH-Managed-Care@omh.ny.gov

 

October 2, 2015: Managed Care Update 1

After what may have seemed like a long wait, the behavioral health managed care role out in NYC is now underway!  Thank you to everyone who has been a part of shaping this program.  There is still much work ahead and we look forward to your continued input into this process.  Over the next few weeks we will be sending out frequent emails and notices to keep you in the loop of what is happening.  This is the first of those communications.

Attached you will find two document that were issued this week.  The first the Behavioral Health Policy Guidance for the Transition of Behavioral Health Benefit into Medicaid Managed Care and Health and Recovery Program Implementation.  This document supports the contract between NYC plans and providers.  Plans will be expected to manage member benefits in a manner that is consistent with this guidance.  We are sharing it with you as information to your members.  This document is subject to change over time as new or revised policies are added.

Also attached is a notice that was sent to NYC Medicaid Managed Care plans related to a claims issue that was identified through claims testing.  The issue is related to unlicensed practitioner claims.  The State is working with all plans, vendors and clearinghouses to ensure this issue is addressed and that claims will be paid when the practitioner delivering the service is an unlicensed practitioner.  OMH is aware of the importance of resolving this issue as quickly as possible.  We encourage you to share this notice with your billing vendors and staff.

OMH is setting up a process for submitting questions and concerns as implementation moves forward. More information will be forthcoming on this process next week.

 

Additional Presentations and Resources:

Measurement and Reporting from the Payer Perspective: A Look at Trends in Performance Requirements - presentation by Steven E. Ramsland, Senior Associate, OPEN MINDS

Managing Risk-Based and Performance-Based Contracting - presentation by Steven E. Ramsland, Senior Associate, OPEN MINDS

Performance Measures: What Payers Are Looking for From Provider Organizations - presentation by Sharon Hicks, COO, Community Care BHO

Medicaid Matters 2014-15 Managed Care Budget Agenda

Will Managed Care Advance Community Mental Health - written by Michael Friedman for Behavioral Health News Spring 2014 Issue

New York State Appellate Court Recognizes Implied Private Right of Action Under the Prompt Pay Law - Recently, in Maimonides Med. Ctr. v. First United Am. Life Ins. Co. (2014 NY Slip Op 1441), the Appellate Division, Second Department held that Insurance Law 3224-a, known as the Prompt Pay Law, affords an implied private right of action, and that a health care provider may thus assert claims against an insurer for its alleged violation of the statute. Plaintiff, Maimonides Medical Center (“Maimonides”) furnished medical care and treatment to six patients who had supplemental Medicare insurance coverage policies with First United American Life Insurance Company (“First United”). Maimonides billed First United for more than $19 million for services rendered to those six patients. In response, First United paid Maimonides slightly more than $4 million. Following this, Maimonides filed a lawsuit against First United alleging, among other causes of action, violations of the Prompt Pay Law.