Tailored Plans: What’s Next for North Carolina Medicaid’s Mental Health System?
By Chad Stage, Manager of Behavioral Health Programs, Emtiro Health
Over the past 20 plus years, the Mental Health/Substance Use Disorder/Intellectual Developmental Disabilities (MH/SUD/IDD) delivery system has become accustomed to change. In this time, the system has transitioned from the one-stop-shop “Area Authorities,” to the Local Management Entities (LME) system and privatization of services to the current Local Management Entities/Managed-Care Organizations (LME/MCO) structure.
Unfortunately, the frequency of these reforms has left us with a behavioral health system that is constantly trying to catch up with itself. As North Carolina prepares for the transformation of its Medicaid program, the MH/SUD/IDD world braces itself for yet another major shift from the current LME/MCO system to the world of Tailored Plans (TPs). As with any reform, this transformation will create confusion for consumers, families, and providers, and anxiety as they wonder how this change will affect them. This transformation could arguably be a more drastic change than any previous iteration of reform that came before it.
First, what is a TP?
Under NC Medicaid Transformation, TPs are prepaid health plans (PHPs) that will serve patients who have Severe and Persistent Mental Illness (SPMI), Substance Use Disorders, or an I/DD diagnosis. Enrollees will be identified as eligible for TP’s by scheduled reviews of claims and encounter data by the North Carolina Department of Health and Human Services (NCDHHS). Patients who meet the criteria for TPs will be auto enrolled when tailored plans launch.
Enrollees eligible for Tailored Plans can opt out of the TP and be covered under a Standard Plan (SP) if the enrollee chooses. Standard Plans are the prepaid health plans that the majority of Medicaid and Health Choice enrollees will enroll in. These plans have already been identified by NC DHHS. However, those who opt out and receive coverage from a SP will not be able to access enhanced services such as the Assertive Community Treatment Team (ACTT) or, for children, Intensive in Home (IIH) services. In addition, patients with an I/DD diagnosis that opt out of the TP will not be eligible for the Innovations Waiver.
The TPs are scheduled to be implemented in the second phase of Medicaid Transformation, as the SPs will be the first to be implemented. Initially, only the seven current LME/MCO’s will be able to respond to the Request for Applications (RFA) to become a TP.
NC DHHS plans to use existing geographical catchments to make up the TP Regions (See Figure 1). It is important to note that these regions do not align with the well-known six Medicaid regions that have guided Medicaid Transformation and service areas for SPs. Up to seven contracts can be awarded, but if an existing LME/MCO within a region is not selected, then the Department may award all or part of that region to one of the other qualifying applicants. With the current suspension of this process due to a budgetary impasse, we do not know if the implementation timeline of TPs will be affected, but they are currently scheduled to launch in 2021. This is an important point for NC DHHS to clarify for stakeholders.
Why is this reform different?
Previous reforms of the behavioral health system in NC have been focused solely on the delivery and oversight of MH/SUD/IDD services for all North Carolina Medicaid enrollees. Regardless of whether a patient was diagnosed with mild depression or if they were managing a Severe Persistent Mental Illness (SPMI), NC Medicaid enrollees sought treatment through the LME/MCO’s and their network of credentialed providers.
Under Medicaid transformation, enrollees with mild and moderate MH/SUD/IDD diagnosis would receive their Medicaid Coverage from one of the 5 SPs. These patients’ medical and behavioral health needs will be treated by providers within their SP’s provider network. Similarly, those patients who meet the criteria for a TP would receive their care from medical and behavioral health providers within the TP provider network.
In contrast to the current LME/MCO system, the TPs will be responsible for not only the MH/SUD/IDD needs of their members but also for their physical health needs: an area that has not historically been in the wheelhouse of the LME/MCOs.
This change in scope of covered services, as well as the care management and provider network responsibilities that come along with it, present a significant learning curve for the LME/MCOs. To help with the provider network, TPs are required to develop contractual relationships with the SPs.
Currently, LME/MCOs provide Care Coordination (CC) services to their “High Cost/High Risk” members. Historically, these were defined as members that have incurred a certain number of Emergency Department (ED) visits (with a primary diagnosis of MH/SA/IDD) and/or a certain number of inpatient psychiatric stays in a given calendar year. Under TPs, a much more intensive service will be mandated, and the TPs will be required to provide continuous Care Management (CM) for their members. See the chart below for more details regarding this care management approach.
There are three potential options for how the Tailored Plans can ensure this level of care management is delivered to their members. First, is the AMH+ model, in which a primary care practice attests that it can provide the required care management services for their assigned patients enrolled in a TP. Second, is the Care Management Agency (CMA) model, in which a provider of MH/SUD/IDD services provides care management for the population. And finally, the TP is accountable for assuring that all enrollees receive the appropriate level of care management, either by providing it directly or through oversight of AMH+ and/or CMA providers (See Figure 2).
The Department has stated that there will be a certification process for any AMH+ or CMA that wishes to attest to assuming care management responsibilities of this population. However, to date, this certification process is not finalized.
NC DHHS has set an expectation that TPs will contract with AMH+ and/or CMAs assuring that 80% of enrollees receive care management from this provider-level care management. It is unclear at this time what level of interest there will be among providers, or level of readiness, to be an AMH+ or CMA. TPs are expected to work with providers in the network to prepare them to operate as AMH+ or CMAs and to assure that the provider network includes AMH+ and/or CMA providers.
Another big change coming to MH/SUD/IDD provider world are the robust requirements for data collection and sharing among the TPs, AMH+, and CMAs. This data approach revolves around five key principles including:
Information Accessibility: Behavioral Health I/DD Tailored Plans, AMH+, and CMAs should have access to timely and comprehensive member-level information for the member’s physical, behavioral, I/DD, Traumatic Brain Injury, Long Term Support Services, and pharmacy, and unmet resource needs to support integration under the Tailored Plan Care Management model
Sufficient Data Capabilities: Behavioral Health I/DD Tailored Plans, AMH+, and CMAs should be equipped with an effective and secure data infrastructure, trained staff, and business procedures that allow for responsive care management.
Standard Plan Alignment: Behavioral Health I/DD Tailored Plan care management data and Health Information Technology requirements should be consistent with those developed for Standard Plans to the extent possible, minimizing provider administrative and operational burden as many providers are expected to work with both plan types.
Standardization for Operational Efficiency: Behavioral Health I/DD Tailored Plans, AMH+, and CMAs costs and administrative burdens should be minimized to the extent possible through the development of common data standards and formats.
Member Engagement and Empowerment: Medicaid beneficiaries are the primary owners of their health information. Behavioral Health I/DD Tailored Plans, AMH+, and CMAs should provide members with easy access to their health information in a manner that is easily understood to the extent practicable.
In theory, these principles seem simple. However, there are many complexities that have the potential to make this quite a task for TPs, AMH+, and CMAs. Possible problem areas include:
Information Accessibility: Historically, physical health care teams and MH/SUD/IDD have not communicated well. Often in the current environment, it requires multiple attempts, staff, and professionals to make good communication occur between physical and behavioral health. It is unclear how this will be resolved in the TP model.
Sufficient Data Capabilities: Most TPs will have updated their data systems to prepare for the transformation and will have the financial solvency to do so. However, for AMH+ and CMAs, updating their current EMR or having to purchase one altogether could potentially be a very costly venture. In addition to cost, most AMH+ and CMAs are at capacity as it relates to staffing and additional workflows. This in and of itself could be an unbearable burden.
All in all, the shift to a population-based health strategy for managing the TP population is to be applauded. This system has been historically reactive rather than proactive in its management of members. Oftentimes its members have had to utilize a certain number of crisis services before an escalation in level of care occurs. This approach will better align the TPs to the approach of the SPs and will have a more proactive approach to population management.
North Carolina’s approach to reform of the MH/SUD/IDD system by means of the TPs will be a good step in removing the bifurcated system we have worked within for decades. This new approach will allow the entities with expertise of the MH/SUD/IDD population to truly focus on and serve those members. That being said, there are definitely going to be some bumps in the road that will ultimately impact the patient, families, and providers working within the Medicaid space.