Medicaid Provider Enrollment for Opioid Center of Excellence Specialty

Medicaid Provider Enrollment for Opioid Center of Excellence Specialty Type Gwendolyn Zander Chief of Staff Office of Medical Assistance Programs 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 1

Webinar Logistics Participants other than the presenter are muted This webinar is being recorded Participants may submit questions using the chat box Presenter will not respond to questions until the end of the webinar Sources of the questions will not be identified by name 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 2

Review of MA Bulletin – Purpose Creates a new specialty provider type in the Medicaid system, PROMISe Formalizes the COE program Provides further sustainability for the COE program Allows providers that did not receive a COE grant to receive a COE designation Standardizes processes for COEs to bill MCOs for their services 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 3

Review of MA Bulletin – Eligible provider types 7/7/2020 01: Inpatient Facility 08: Clinic 11: Mental Health/Substance Abuse 19: Psychologist (groups, not individuals) 21: Case Manager (groups, not individuals) 31: Physician (groups, not individuals) www.dhs.pa.gov www.dpw.state.pa.us 4

Background of COEs Timeline – 2016: 45 COEs were selected from grant applications to transform the service delivery model for people diagnosed with opioid use disorder (OUD) – 2019: Transitioned from grant funding to billing Medicaid MCOs for care management services Still bill for other covered Medicaid services separately, such as MAT, lab testing, counseling, primary care, etc. Directed payment arrangement approved by CMS requires MCOs to pay COEs exactly 277.22 per member per month for care management of their enrollees that receive services from the COE – Bill using the G9012 procedure code – MCOs receive a list from DHS of COEs they must contract with and pay – 2021: Only providers enrolled in the Medicaid program as provider specialty type 232-Opioid Centers of Excellence will be paid for the G9012 procedure code 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 5

Goals of COEs Increase access to MAT Coordinate physical and behavioral healthcare Keep individuals engaged in the recovery process along the full continuum of care through community-based care management 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 6

About COEs Who are COEs? – Departments in hospitals/health systems – Primary care providers – FQHCs – Licensed drug & alcohol treatment providers – Mental/behavioral health counseling service providers 7/7/2020 What do COEs do? www.dhs.pa.gov – Provide physical and/or behavioral healthcare services to Medicaid beneficiaries and others – Provide MAT on-site – Provide care management services – Use relationships with other treatment and recovery support service providers in their communities to create and implement a comprehensive care plan that treats the whole person – Use a blend of licensed and nonlicensed, or clinical and nonclinical, staff to treat clients www.dpw.state.pa.us 7

Applications Process for Applying – Complete and execute the required supplemental provider agreement Electronic signatures are permissible Will discuss contents later in presentation – Complete service description template Will discuss contents later in presentation – Submit PROMISe application for Specialty Type 232- Opioid Centers of Excellence Attach signed supplemental provider agreement and service description Upload supplemental provider agreement and service description with application https://provider.enrollment.dpw.state.pa.us/ – NOTE: Currently designated COEs must submit applications for the specialty type; they will not be automatically enrolled 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 8

Applications When DHS receives an application through PROMISe, it will review the supporting documentation – Application review support will be provided by the University of Pittsburgh School of Pharmacy Program Evaluation & Research Unit (Pitt PERU) – Pitt PERU staff will review the applications and DHS will make the ultimate decision regarding enrollment After an applicant has submitted the application, DHS or PERU staff will coordinate with the applicant to collect any additional information needed to support the application or required revisions – We aim to correct application defects rather than deny applications whenever possible – Critical for applicants to provide information timely and work cooperatively with DHS and PERU staff – Enrollment hinges on approval of the proposed service description 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 9

Applications Receipt of Designation – DHS will determine whether application standards have been met and will decide whether to enroll the applicant with the provider specialty type in PROMISe – If DHS determines the applicant has not met the standards, the applicant may appeal that determination to DHS’s Bureau of Hearings & Appeals – Providers enrolled with Specialty Type 232 will be the only providers who may be paid for procedure code G9012 claims beginning January 1, 2021 If an enrollment decision has not been made yet as of January 1, the enrollment may be made retroactive so that COEs may submit claims for dates of service beginning the date of the enrollment 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 10

Technical Assistance and Learning Network Technical assistance will be available to enrolled COEs to assist them with the implementation of the COE model of care. All enrolled COEs are expected to participate in a COE Learning Network – Virtual webinars or other programs on specific topics relevant to the operation of a COE – Statewide in-person conference for all COEs (may be virtual if necessary) 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 11

Bulletin Timelines Bulletin effective date: 7/1/2020 – Applications can be submitted at any time after effective date No due date for applications – Applications received after 9/1/2020 cannot be guaranteed to have been reviewed/approved prior to 1/1/2021 Provider Specialty Enrollment Required to Bill for G9012 Procedure Code: 1/1/2021 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 12

Service Description Must demonstrate that the applicant has developed policies, protocols, and procedures to operationalize the requirements – Focused on documentation of these policies, protocols and procedures – Can include narrative of plans to develop these if they do not exist yet 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 13

Service Description Provider Name must be the exact name reflected in PROMISe MCOs and Primary Contractors – For Physical Health providers, include the name of each of the Physical Health MCOs that operate in the zone(s) in which you are located See http://www.healthchoices.pa.gov/providers/about/physical/index.htm for a map of the zone and the names of the MCOs that operate in each zone – For Behavioral Health providers, include the name of the county contractor(s) for the counties you serve. You must also include the name(s) of the behavioral health MCOs that serve those counties. See http://www.healthchoices.pa.gov/providers/about/behavioral/index.htm for a list of zones, counties in those zones, and the MCOs that serve those counties 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 14

Service Description COE must demonstrate its ability to provide at least one form of medication approved by the Food and Drug Administration for use in MAT at the enrolled service location in which COE Services are offered and to schedule clients for MAT induction within 24 hours of the COE Member’s initial encounter with the COE Provider – DHS does not have any preference regarding which form of medication is provided on-site – 24 hours includes weekends 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 15

Service Description COE must demonstrate its ability to ensure that each COE client receives an American Society of Addiction Medicine (ASAM) Level of Care Assessment, conducted by either an employee of the COE or a qualified provider who accepts referrals from the COE – COE does not need to employ an individual qualified to perform a LOCA, but must have the ability to have a LOCA completed timely for every client – The LOCA will identify the appropriate level of care, and, if MAT is appropriate, the preferred form of medication based on clinical appropriateness and client choice 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 16

Service Description COE must demonstrate its ability to refer and connecting COE clients as clinically appropriate to all ASAM levels of care within the timelines prescribed by the HealthChoices Program’s Service Access Standards for emergency, urgent, and routine situations. – Every single level of care must be accessible to all clients within the required timelines – ASAM levels of care can be found at https://www.asamcontinuum.org/knowledgebase/what-are-the-a sam-levels-of-care/ – Timeliness standards can be found at http://www.healthchoices.pa.gov/cs/groups/webcontent/docume nts/manual/p 003130.pdf on page 52 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 17

Service Description COE must demonstrate its ability to provide each of the following services directly or by referral to the COE Member’s choice of provider enrolled in Pennsylvania’s Medicaid Program: – – – – – – – Primary care, including screening for and treatment of positive screens for: HIV, Hepatitis A (screening only); Hepatitis B; Hepatitis C; and Tuberculosis Perinatal Care and Family Planning Services Mental Health Services Forms of medication approved for use in MAT not provided at the COE Provider’s enrolled service location(s) Even though COEs must only provide one form of MAT medication on-site, they must have the ability to connect members to all FDA-approved forms of medication based on clinical appropriateness and client choice MAT for pregnant women, if the COE Provider does not provide MAT to pregnant women Drug and Alcohol Outpatient Services COE does not need to be a DDAP licensed drug and alcohol treatment provider Pain Management For any of these services not provided on-site, the applicant can demonstrate its ability to make warm hand-offs to providers of these services through documentation such as letters of support, memoranda of understanding, etc. 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 18

Service Description COE must demonstrate its ability to accept referrals 24 hours per day, 7 days per week, through mobile engagement teams that facilitate warm hand-offs by traveling to the location where an individual in need of COE services presents. – Examples of these locations are emergency departments, jails or prisons, sites where an overdose occurred, client’s home, etc. – Warm hand-offs can occur from an emergency department to treatment services, from treatment services to non-treatment recovery support services, or between levels of care for treatment services. 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 19

Service Description COE must demonstrate its ability to utilize an assessment tool or questionnaire to identify a client’s treatment and non-treatment needs and to refer clients to resources for identified non-treatment needs and social determinants of health – This assessment should be completed early in a client’s engagement with the COE to inform the development of the care plan and should be completed periodically during treatment to ensure needs have not changed – Examples of social determinants of health are transportation, housing, nutrition/food, education, employment, training, legal services, and childcare – The COE does not need to provide services related to non-treatment needs directly but must have relationships with community providers that can assist in these areas. These relationships can be demonstrated through documentation such as letters of support, memoranda of understanding, or any other evidence of an existing or planned relationship. 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 20

Service Description COE must demonstrate its ability to employ a community-based care management team, which must include a Certified Recovery Specialist credentialed by the Pennsylvania Certification Board, and may include peer navigators, nurses, social workers, and other provider types – The COE must employ sufficient staff to effectively manage their predicted caseloads – These staff do not need to be directly employed by the COE and may be contracted employees (i.e., employees of another entity that are contracted to provide services to COE clients) 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 21

Service Description COE must demonstrate its ability to provide access to naloxone to COE Members for overdose prevention purposes – The COE itself does not need to provide naloxone to clients but must be able to help a client obtain a prescription using the Physician General’s standing order or a free dose through the county coordinating entity – For more information about accessing naloxone doses, please see https://www.pa.gov/guides/opioid-epidemic/#GetNaloxone 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 22

Service Description COE must demonstrate its ability to administer the Brief Assessment of Recovery Capital survey to each COE client – Must be administered within 30 days of the initial encounter with the COE Provider – Must re re-administered at six-month intervals – Must collect and report the results of the survey administration to the Department – To view the BARC-10 survey questions, please go to http://shura.shu.ac.uk/15835/2/Best%20-Development%20and%20valid ation%20of%20a%20Brief%20Assessment%20of%20Recovery%20Ca pital%20%28BARC-10%29%20%28Scale%29.pdf 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 23

Service Description COE must demonstrate its ability to: – Utilize electronic health records to document care management activities Ideally this would be an EHR or EMR system Any secure electronic recordkeeping system is acceptable; paper records are not – Comply with relevant federal and state confidentiality laws concerning protected information If you have questions about which statutes and regulations apply, please consult counsel 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 24

Service Description COE must demonstrate its ability to: – Use a formalized and documented quality improvement process For information about quality improvement processes or continuous process improvement, please see https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod4.html#: :text I n%20health%20care%2C%20quality%20improvement,analyzed%2 C%20improved%2C%20and%20controlled. – Comply with the requirements of 62 P.S. § 1406(a) and 55 Pa. Code § 1101.63(a) by agreeing not to charge any Medicaid enrollee for covered services Please refer to the regulation at http://pacodeandbulletin.gov/Display/pacode?file /secure/pacode/d ata/055/chapter1101/s1101.63.html&d reduce 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 25

Service Description Program philosophy, goals and objectives can be demonstrated through: – Mission or vision statement – A list of evidence-based practices used or to be used by the COE Provider – A list of goals for the COE Provider as a program and for clients receiving COE care management services from the COE Provider – Objectives that support the achievement of those goals. 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 26

Service Description Expected outcomes can be demonstrated through a list of quantitative measures, such as targets for: – Number of clients to receive COE care management services per month – Average duration of COE care management service receipt – Rate of referrals to each service identified in Description of Service above – Average improvement of scores on the Brief Assessment of Recovery Capital survey 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 27

Supplemental Provider Agreement This is the legal document that will hold the COE to providing services in accordance with its approved service description Fill in the name of the applicant in the first paragraph Must be executed by an individual with authority to bind the COE If you do not know your MPI number, please call 1-800-537-8862 The FEIN is the federal employer identification number used by the IRS for tax purposes – This can be found on a W-2 form of any employee or by contacting your organization’s HR department DHS and PERU will use the telephone number and email address on the provider agreement to contact the applicant if additional information or revisions are needed 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 28

Resources MA Bulletin DHS Centers of Excellence Webpage Provider Enrollment Application Portal Physical HealthChoices Zones Behavioral HealthChoices Zones ASAM Levels of Care HealthChoices Service Access Standards – see page 52 Accessing Naloxone BARC-10 Survey Quality Improvement Processes MA Payment In Full Regulation DHS Provider Hotline Toll-Free Number: 1-800-537-8862 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 29

Questions Type your questions into the chat box; they will be answered in the order they are received If your question was not answered today, please email [email protected] 7/7/2020 www.dhs.pa.gov www.dpw.state.pa.us 30