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Drug Medi-Cal

Organized Delivery System

Waiver

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 Institute for Mental Disease

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

is considered an IMD• Clients in IMD’s restricted from all MediCal services• Without the DMC-ODS Waiver Pilot, California

cannot provide residential services

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Development of DMC-ODS

• Conducted a SUD Needs Assessment• Program Integrity Issues• Physical and Behavioral Health Integration• Merging of Departments• Screening Brief Intervention and Referral

Treatment in Managed Care (SBIRT)

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Stakeholder Process• January 2014- DHCS began the

stakeholder engagement process• April 2014- DHCS held three Waiver

Advisory Group (WAG) meetings• July 2014- DHCS released draft Standard

Terms and Conditions (STCs)

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Stakeholder Process• Additional WAGs were held in July 2014,

January 2015, Feb 2015 and March 2015• 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 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• Provide availability of all SUD services• Place client in the least restrictive level

of care

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DMC Organized Delivery System Waiver

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 MediCal 2020 1115 Waiver

• Pilot for 5.5 years• Does not require a change in Statute or

regulations• Counties choose to opt-in• 53 of 58 counties expressed an interest

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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)

• One level required for DMC-ODS• No bed capacity limit • The length of residential services range

from 1 to 90 days with a 90-day maximum for adults

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Residential

• Medical necessity can authorize a one-time extension of up to 30 days on an annual basis

• Only two non-continuous 90-day regimens will be authorized in a one-year period

• Perinatal clients may receive a longer length of stay based on medical necessity

• 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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Additional Medication Assisted Treatment

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Medication TAR* Required Availability Methadone No Only in NTP/OTP Buprenorphine Yes, unless

provided in an NTP/OTP

Pharmacy Benefit, NTP/OTP

Naltrexone tablets No Pharmacy Benefit, DMC Benefit

Naltrexone long-acting injection

Yes Pharmacy Benefit, Physician Administered Drug

Disulfiram No Pharmacy Benefit, NTP/OTP

Acamprosate Yes Pharmacy Benefit Naloxone No Pharmacy Benefit;

NTP/OTP

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• Physician consultation services with addiction

medicine physicians, addiction psychiatrists or clinical pharmacists

• 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• Additional Lengths of Stay (up to 6

months residential; 3 months Federal Financial Participation (FFP) with a one-time 30-day extension)

• If longer lengths, other county identified funds can be used

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Provider Specifications• Addition of LPHAs: Physician, Nurse

Practitioners, Physician Assistants, Registered Nurses, Registered Pharmacists, Licensed Clinical Psychologist (LCP), Licensed Clinical Social Worker (LCSW), Licensed Professional Clinical Counselor (LPCC), and Licensed Marriage and Family Therapist (LMFT)

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County Responsibilities

• Selective Provider Contracting• Access to Services• Medication Assisted Treatment• Contracting Requirements• Provider Appeals Process• Residential Authorization

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County Responsibilities

• County Implementation Plan• County Fiscal Plan• Two Evidence Based Practices

(motivational interviewing, Cognitive-Behavioral Therapy, Relapse Prevention, Trauma-Informed Treatment, Psycho-Education)

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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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County Responsibilities

• Beneficiary Access Number• Care Coordination with Mental and

Physical Health Services• State/County Contract

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State Responsibilities• Integration Plan• Innovation Accelerator Program• ASAM Designation for Residential facilities• Oversee Provider Appeals Process• Monitoring Plan

– Timely Access– Program Integrity– Triennial Reviews

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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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FinancingRates• Counties will negotiate provider rates by

modality (except for NTP Services which will remain set by DHCS)

• The state will have final approval of the rates

• If the state rejects the rates, the county can resubmit revised rate

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FinancingRealignment• Counties receive realignment funds

derived from sales tax revenues deposited into their Behavioral Health Subaccount to pay for a portion of DMC treatment services 

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Financing• The cost of all DMC Waiver services will

be shared among the federal government, State government and the counties

• The Federal government will continue to pay FFP for the existing population (mandatory) at the 50% rate (including residential services)

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Financing

• The Federal government will pay FFP for the expansion population at the applicable enhanced rate (including residential), currently 100%, decreasing to 95% in 2017, and so on until reaching 90% in 2020 and beyond

• Sharing Ratio is county specific

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Financing

• The non-federal share will be split between the State/County based on a county-specific State/County sharing ratio

• Quality Assurance Activities will be reimbursed at 75% FFP

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Financing

• The sharing ratio will apply to outpatient, intensive outpatient, NTPs (including buprenorphine and disulfiram), recovery services, case management, physician consultation, residential, quality assurance activities, and county administration services

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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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• Regional ImplementationPhase I – Bay Area (May-August 2015)

Phase II – Southern California

Phase III – Central Valley

Phase IV – Northern California

Phase V – Tribal Delivery System

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DMC-ODS Waiver Implementation

• Next Waiver Advisory Group Meeting– Between Phase One and Two

• County Regional Waiver Meetings– Phase One meeting: May 2015– Phase Two meeting: October 2015

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DMC-ODS Waiver 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

Implementation Responsibilities

PTRS Division• IT Changes to Short-Doyle• State/County Contract• DMC Monitoring Protocol

Provider Enrollment Division• DMC Certification

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Implementation ResponsibilitiesSUD Compliance Division• County and Fiscal Implementation Plans• Provider Appeals Process• ASAM Designation for Residential• External Quality Review Organization• Expansion of MAT• Coordinate WAGs and EAGs

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Implementation Responsibilities

SUD Compliance Division• UCLA Evaluation• Training Plan and Contract• Technical Assistance• County Liaisons• Integration Plan• CMS- Innovation Accelerator Program

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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