Significant changes are taking place in 2015 and 2016 in the delivery of behavioral health care in Medicaid managed care. This article will continue to be updated as information becomes available from the Department of Health.
Behavioral Health Carve Outs
For many years, people who are certified disabled under Medicaid have had their behavioral health services "carved out" of the Medicaid managed care benefit package, meaning that while other services transitioned to managed care, behavioral health remained fee for service.
Those who receive mental health services but are not certified disabled have had the coverage carved-in for as long as they have had managed care.
In 2015 and 2016 behavioral health will be carved into the Medicaid managed care benefit package for all members, including those who are certified disabled.
What is the Difference Between Fee for Service and Managed Care?
In fee-for-service Medicaid, beneficiaries can go to any doctor who takes Medicaid. This is called fee-for-service because the doctor or provider gets a fee every time he/she provides a service to a Medicaid beneficiary.
In managed care, the plan is paid a capitated rate (flat monthly fee) to provide for nearly all of the beneficiary’s health care needs.
In Medicaid managed care, enrollees can only see the doctors and other health providers in their plan’s network, and must follow the plan’s rules for accessing care. In addition, they will be assigned a primary care provider and must go to this provider in order to get a referral for specialty care and prior authorizations for non-emergency hospitalizations and many other services.
Under the new program, behavioral health for certified disabled members will be carved into the Medicaid managed care program. This means that members will have to seek out mental health services with providers within the member’s managed care plan.
In order to qualify to deliver behavioral health services, all mainstream plans were required to submit applications to the NYS Department of Health demonstrating that they are capable of effectively managing behavioral health services, either independently or in cooperation with a specialized Behavioral Health Organization (BHO).
Individuals with serious behavioral health issues have two different types of plan options: they can join a Health and Recovery Plan (HARP) or a mainstream Medicaid managed care (MMC) plan. All mainstream plans must be qualified to serve individuals with serious behavioral health issues in order to enroll this population.
Individuals with serious mental illness or substance use disorders will be eligible for a HARP plan, but this is optional. These plans will be offered by many of the same plans that offer mainstream plans and will be specifically geared towards those with significant behavioral health needs.
Those plan enrollees who are determined by New York State to be HARP eligible based on past Medicaid usage will receive a notice in April, May, or June (depending on birthdate) stating that they will be enrolled into a HARP unless they opt out by July 1, August 1, or September 1 respectively. They may opt out by calling New York’s Medicaid enrollment broker, New York Medicaid CHOICE at (800) 505-5678. If they opt out they will remain in their current mainstream managed care plan, which will begin covering their behavioral health benefit on July 1.
HARPs will manage care for adults with significant behavioral health needs. They are designed to facilitate the integration of physical health, mental health, and substance use services for individuals requiring specialized expertise, tools, and protocols which are usually not found in managed care plans. In addition to the State Plan Medicaid services offered by mainstream MMCs, qualified Health and Recovery Plans will offer access to an enhanced benefit package comprised of 1915(i)-like Home and Community Based services designed to provide the individual with a specialized scope of support services not currently covered under the State Plan.
Individuals identified as HARP eligible, who have already enrolled in an MCO that also offers a HARP, will be passively enrolled in that Plan’s HARP.
Individuals identified for passive enrollment will receive a letter from New York Medicaid CHOICE and will be given 30 days to either opt out of their plan’s HARP or choose to enroll in another HARP. If they do not opt out or affirmatively join another HARP, they will be enrolled in their plan’s HARP on July 1.
Once enrolled in a HARP, members will be able to switch their plan at any time in the first 90 days of enrollment. After the first 90 days, they will be locked into the HARP for nine months.
Individuals initially identified as HARP eligible who are already enrolled in an MCO without a HARP will not be passively enrolled. They will be notified of their HARP eligibility and referred to NY Medicaid CHOICE to help them decide which plan is right for them.
Qualified Mainstream MCOs
For all adults served in mainstream MCOs throughout the State, the qualified MCO will integrate all Medicaid State Plan covered services for mental illness, substance use disorders (SUDs), and physical health conditions. (https://www.omh.ny.gov/omhweb/bho/phase2.html)
On April 1, 2015 the process of passive enrollment into HARPS will begin.
On July 1, 2015, the carve-in of the behavioral health benefit to Medicaid managed care will begin for adults in New York City.
On October 1, 2015, the carve-in of the behavioral health benefit to Medicaid managed care will begin for adults in the rest of New York State.
In January 1, 2016 the carve-in of the behavioral health benefit to Medicaid managed care will begin for children.
Medicaid Managed Care (http://www.wnylc.com/health/entry/160/)
Implementing Medicaid Behavioral Health Reform in New York (https://www.health.ny.gov/health_care/medicaid/redesign/docs/2013-12-17_webinar_bh_manage_care.pdf)
New York State Department of Health Behavioral Health Transition to Managed Care* (http://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health_transition.htm)
New York State Office of Mental Health- Behavioral Health Managed Care Part 2 (https://www.omh.ny.gov/omhweb/bho/phase2.html)
Update on NYS Behavioral Health Managed Care Transition (http://www.omh.ny.gov/omhweb/News/2015/behavioral-health-implementation-update.pdf)
New York Request for Qualifications for Behavioral Health Benefit Administration: Managed Care Organizations and Health and Recovery Plans
*The timeline for this transition has continued to change, so many dates may be incorrect.