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Drug Medi-Cal

Organized Delivery System

Waiver

Presented by

Karen Baylor, PhD, Deputy Director, MH/SU Division, DHCS

and

Patricia Ryan, MPA

Consultant, CBHDA

DMC Benefits Prior to ACA

• Mandatory Population Only• Modalities

– Outpatient Drug Free (ODF) - all mandatory populations

– Narcotic Treatment Programs (NTP) - all mandatory populations

– Residential (perinatal only in non-IMDs)– Intensive Outpatient Therapy (IOT) - perinatal only

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ACA Expansion

• Increased Eligible Beneficiaries (Expanded Population)

• CA chose to expand modalities– IOT (for Mandatory and Expanded

Populations)– Residential (for Mandatory and Expanded

Populations)

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ACA ExpansionResidential Services• Residential needed in the continuum of care• Restricted due to the federal Medicaid Institutions for

Mental Disease (IMD) exclusion• Ninety percent of California’s residential bed capacity

is considered an IMD• Medicaid payment is not allowed for any services

provided to Medi-Cal clients in IMDs• Without the DMC-ODS Waiver Pilot, California

cannot provide residential services4

DMC Organized Delivery System Waiver

• The goal is to improve Substance Use Disorder (SUD) services for California beneficiaries

• Authority to select quality providers• Consumer-focused; use evidence-based

practices to improve program quality outcomes• Support coordination and integration across

systems

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DMC Organized Delivery System Waiver

• Reduce emergency rooms and hospital inpatient visits• Ensure access to SUD services• Increase program oversight and integrity• Place client in the least restrictive level

of care

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Stakeholder Process• DHCS held Nine Waiver Advisory Groups• Participants: counties, provider associations,

Alcohol and Other Drug counselor certifying organizations, managed care health plans, public interest advocates, and legislature

• Meeting notes posted on the website

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DMC Services SPA 13-038 ( Non-Waiver

Opt-in Waiver

Outpatient/Intensive Outpatient

X X

NTP X X

Residential X (one level)

Withdrawal Management X (one level)

Recovery Services X

Case Management X

Physician Consultation X

Additional MAT X (optional)

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General Provisions

• Amendment to Bridge to Reform and folded into Medi-Cal 2020 1115 Waiver

• Pilot for 5.5 years• Counties choose whether to opt-in• 53 of 58 counties expressed an interest• ASAM Criteria

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Early Intervention Services• SBIRT (screening, brief intervention and

referral to treatment) American Society of Addiction Medicine (ASAM) Level 0.5

• Provided by non-DMC providers to beneficiaries at risk of SUD (through FFS system)

• Referrals by managed care providers or plans to DMC-ODS will be governed by the Memorandum of Understanding

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Outpatient• ASAM Level 1• Individual and group counseling up to 9 hours a

week for adults • Determined by a Medical Director or Licensed

Practitioner of the Healing Arts (LPHA)• Services can be provided in-person, by

telephone or by telehealth (except group)• Addition of family therapy

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Intensive Outpatient• ASAM Level 2.1• Minimum of nine hours with a maximum of

19 hours a week for adults• Determined by a Medical Director or LPHA• Services can be provided in-person, by

telephone or by telehealth (except group)• Addition of family therapy

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Partial Hospitalization

• ASAM Level 2.5• 20 or more hours of clinically intensive

programming per week• Providing this level of service is optional

for participating counties

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Residential

• 5 Levels of Residential Based on ASAM (Levels 3.1, 3.3, 3.5, 3.7 and 4.0)

• No bed capacity limit • Services range from 1 to 90 days • CDRH and Acute Free Standing Psych

paid through the FFS system

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Withdrawal Management• (Levels 1, 2, 3.2, 3.7 and 4 in ASAM) • Determined by a Medical Director or LPHA• Monitored during detoxification • IMD expenditure approval for Chemical

Dependency Recovery Hospitals and Free Standing Psychiatric Hospitals (paid through FFS system)

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Opioid (Narcotic) Treatment Program

• ASAM OTP Level 1• Required service in all opt-in counties• Adding buprenorphine, disulfiram and

naloxone in NTP settings• Minimum fifty minutes of counseling

sessions up to 200 minutes per calendar month or more with medical necessity

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Additional Medication Assisted Treatment

• The goal of the DMC-ODS for Medication Assisted Treatment (MAT) is to open up options for patients to receive MAT by requiring MAT services in all opt-in counties, educate counties on the various options pertaining to MAT and provide counties with technical assistance to implement any new services.

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Recovery Services• May access recovery services after

completing the course of treatment, if triggered, if relapsed or as a preventative measure to prevent relapse

• Provided face-to-face, by telephone, or by telehealth with the beneficiary and may be provided anywhere in the community

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Case Management

• Counties will coordinate case management services

• Services can be provided in various locations

• Coordinate with Mental and Physical Health• Provided face-to-face, by telephone, or by

telehealth

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Physician Consultation Services

• Designed to assist DMC physicians with treatment plans for DMC-ODS beneficiaries

• Medication selection, dosing, side effect management, adherence, drug-to-drug interactions, or level of care considerations

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Criminal Justice System• More parolees and probationers eligible for Medi-

Cal with ACA expansion• Many parolees and probationers have unmet SU

needs• If longer lengths of treatment are needed, other

county identified funds can be used• DHCS collaborating with CDCR’s Integrated Care

Committee to redesign treatment services for parolees

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County Responsibilities• Assure Beneficiary Access to Culturally

Competent Services• Medication Assisted Treatment• State-County Contract Requirements• Provider Appeals Process• Authorization of Residential Services• Coordination with DMC-ODS Providers

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County ResponsibilitiesSelective Provider Contracting:• Must maintain client access to services• Must provide a continuum of care with the

required services• Must have policies & procedures for selection,

retention, credentialing and re-credentialing• Must ensure services are culturally competent

County Responsibilities• County Implementation Plan• Two Evidence-Based Practices• Beneficiary Access Number• Care Coordination with Mental and

Physical Health Services (Integrated Care)• State/County Contract• Residential Authorization

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County Responsibilities

County Implementation Plan• County implementation plans must ensure

that providers are appropriately certified for the services contracted, implementing at least two evidence-based practices, trained in ASAM Criteria, and participating in efforts to promote culturally competent service delivery.

County Responsibilities• MOU with all managed care providers

– Comprehensive Screening– Beneficiary Engagement– Shared Plan Development/Treatment Planning– Case Management Activities– Dispute Resolution– Care Coordination/Referral Tracking– Navigation Support

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Quality Improvement• Counties must have:

• QI Plan• QI Committee• Review Accessibility of Services Data• Utilization Management Program• Participate in Annual External Quality Reviews

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State Responsibilities• Provider Certification• Approve Integration Plan• Innovation Accelerator Program• Approve ASAM Designation for

Residential Facilities• Oversee Provider Appeals Process• Monitoring Plan

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New Opportunities• Many new Med-Cal enrollees under ACA expansion have

SUD needs, including criminal justice population• Under “Public Safety” state-county realignment, county

incentives to address unmet needs are increasingly aligned

• DMC-ODS gives state/counties the tools to work with primary care/mental health to deliver integrated/coordinated services in a culturally competent, recovery-oriented way

• New tools to work toward “triple aim” goal of ACA

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CMS SMD #15-003

• CMS issued a guidance letter July 27, 2015 to inform states of opportunities to design service delivery systems for individuals with SUD.

• California is the first state to receive approval under this guidance.

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Evaluation

• University of California, Los Angeles, (UCLA) Integrated Substance Abuse Programs will conduct the evaluation

• Four key areas of access, quality, cost, and integration and coordination of care

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Federal 438 Requirements

• Counties held to all federal 42 CFR 438 requirements (quality assurance, beneficiary protections, access)

• External Quality Review requirements must be phased in within 12 months of having an approved implementation plan

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Tribal Delivery System

• DHCS will consult with the tribes and the four tribal 638/urban programs after approval of the amendment

• Phase 5 implementation will focus on the tribal system after the amendment has been approved by CMS

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Phase I – Bay Area

Phase II – Southern California

Phase III – Central Valley

Phase IV – Northern California

Phase V – Tribal Delivery System

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Regional Implementation

Technical Assistance from DHCS• State Implementation Plan• Designing a Training Plan• DHCS Substance Use Disorders

Statewide Conference

“Organizing the SUD Delivery System”

October 26-27, 2015

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DMC-ODS Waiver Implementation

Final Thoughts

All eyes are on California, so let’s make sure we do this right!

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• DHCS DMC-ODS Website• http://

www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx

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DMC-ODS Waiver Implementation