Ohio’s behavioral health service delivery and payment systems are heading in a new direction. Over the next three years, we expect providers and service recipients to experience significant changes as alterations are made to the state’s determination of eligibility, authorized providers, covered services, and payment amounts and methods. This is the first post of a four-part series that will provide an overview of the coming changes and more detailed discussions of three separate but related areas of the redesign over the coming weeks:
- New disability determination and a new 1915(i) state plan benefit;
- Redefining existing services to align with national coding standards; and
- Moving behavioral health into managed care.
The following paragraphs provide a “big picture” overview of each redesign area.
Disability determination changes and the 1915(i) amendment
The recent passage of Ohio’s 2016-2017 biennial budget (H.B. 64) has enabled Ohio to pursue a variety of eligibility changes, with the goal of streamlining eligibility determination processes. One important component of the changes, the elimination of the ‘spenddown’ process, will impact some adults with serious mental illness. With creative use of a little-used Medicaid option, which is targeted to go into effect in July 2016, the state is working to maintain eligibility for affected individuals. To assure continued essential to community based services within this population, the state is pursuing a new Medicaid 1915(i) state plan amendment that would provide eligibility to an estimated 5,000 people. The Ohio Department of Medicaid intends to submit the 1915(i) state plan amendment to the Centers for Medicare and Medicaid Services (CMS) before the end of this year. The planned changes to disability determinations and the 1915(i) amendment will be explored in the next post.
Redefining existing services to align with national coding standards
The current menu of behavioral health services available in Ohio has changed very little in more than 15 years and has not kept up with current medical coding conventions. Services such as community psychiatric supportive treatment (CPST), pharmacologic management, substance abuse disorder, medical/somatic, and others are being reviewed for redesign. In the future, providers will need to use industry-standard codes to bill instead of using the codes in place today that are unique to the state. Ohio will also begin using National Correct Coding Initiative (NCCI) edits to standardize payment logic as part of this process. Along with these changes, the state plans to provide coverage for new behavioral health services as part of the redesign process; these may include services such as assertive community treatment, intensive home based treatment, high fidelity wrap around, peer services, supportive employment, and residential substance abuse disorder treatment. The third post in this series will provide greater detail about these coding and service changes, which are currently being discussed in state-led workgroups. July 2016 is the target date for implementing the new service menu.
Implementing managed care for community behavioral health services
Prior to the adoption of H.B.64, Ohio statute precluded alcohol, drug addiction, and mental health services covered by Medicaid from being included in a managed care system, which meant these services were available on a fee-for-service basis. As enacted, the budget bill removed this exclusion. After extensive legislative discussion during the budget process, a modest change was made to the originally proposed timeframes for implementing managed care for behavioral health services. The work to redesign the service menu, as described above, is an essential foundation for transitioning into managed care. Ohio is moving aggressively to prepare for this change over the next twenty eight months, with a target implementation date of January 2018. The fourth blog post in this series will discuss implementing managed care systems for behavioral health services.
The provision of behavioral health services in Ohio will be radically transformed over the next few years. Instead of the current system, which allows any provider who is willing to provide services to receive fee schedule payment amounts for historically familiar services, select panel providers will negotiate with the managed care plans operating in their service area to provide newly defined services. All health care providers – particularly those providing behavioral health services – will need to clearly understand the operational and financial implications of these changes.