Table 1. Benefits in Mainstream MCOs for all Medicaid Populations 21 and over Services Current State Plan SPA Change Submitted Separately from this 1115 Demonstration Amendment but for Inclusion in This Demonstration Currently in NYS 1115 Benefit Package Current delivery System (Either MCO or FFS) Future MCO Benefit Package Medically supervised outpatient withdrawal (OASAS services) Yes Rehabilitation option per 42 CFR 440.130 Yes Managed care for MCO enrollees; FFS for nonMCO enrollees Yes for MCO enrollees Outpatient clinic and opioid treatment program (OTP) services (OASAS services) Yes — clinic option per 42 CFR 440.90 Move to rehabilitation option per 42 CFR 440.130 Outpatient clinic and OTP is FFS for all Medicaid enrollees FFS under clinic option Yes for MCO enrollees Outpatient clinic services (OMH services) Yes — clinic option per 42 CFR 440.90 Temporary assistance to needy families (TANF) and safety net assistance (SNA) only; Managed care for TANF and SNA; FFS for SSI and duals Yes for MCO enrollees Comprehensive psychiatric emergency program Yes — outpatient hospital service (42 CFR 440.20) TANF and SNA only; FFS for all SSI Medicaid recipients Managed care for TANF and SNA; FFS for SSI and duals Yes for MCO enrollees Continuing day treatment Yes — clinic option per 42 CFR 440.90 No FFS only Yes for MCO enrollees Partial hospitalization Yes — clinic option per 42 CFR 440.90 No FFS only Yes for MCO enrollees PROS Yes — rehabilitation option per 42 CFR 440.130 No FFS only Yes for MCO enrollees ACT Yes — rehabilitation option per 42 CFR 440.130 No FFS only Yes for MCO enrollees Intensive case management/ supportive case management Yes — TCM is being phased out; now using Health Home SPA authority No FFS only Yes for MCO enrollees Health Home Care Coordination Yes — Health Home per 1945 of Social Security Act No Managed care for MCO enrollees; Yes for MCO enrollees
FFS for nonMCO enrollees Inpatient hospital detoxification (OASAS service) Yes — inpatient 42 CFR 440.10 Yes Managed care for MCO enrollees; FFS for nonMCO enrollees Yes for MCO enrollees Inpatient medically supervised inpatient detoxification (OASAS Service) Yes — inpatient 42 CFR 440.10 Yes Managed care for for MCO enrollees; FFS for nonMCO enrollees Yes for MCO enrollees Inpatient treatment (OASAS service) Yes — inpatient 42 CFR 440.10 TANF and SNA only; FFS for all SSI Medicaid recipients Managed care for TANF and SNA; FFS for SMI, SSI and duals. Yes for MCO enrollees Inpatient psychiatric services (OMH service) Yes — inpatient 42 CFR 440.10 TANF and SNA only; FFS for all SSI Medicaid recipients Managed care for TANF and SNA; FFS for SSI and duals Yes for MCO enrollees Rehabilitation services for residents of community residences Yes — rehabilitation option per 42 CFR 440.130 No FFS Not initially in the MCO benefit Crisis Intervention No No Proposed (see for service definition) No Yes Community Mental Health Services Licensed Behavioral Health Practitioner Services No No Proposed (See Attachment J for service definition) No Yes for enrollees
The percent of annual determinations where level of need criteria were correctly applied. sample, 95% Confidence Interval (CI). Data aggregation responsible party: MCO and DOH Frequency of data aggregation and analysis: Monthly 2 Participant safeguards/health and welfare: The State identifies addresses and seeks to prevent incidents of abuse, neglect, and exploitation, including the use of restraints. The State demonstrates on an ongoing basis that it identifies addresses and seeks to prevent incidents of abuse, neglect, exploitation, and unexplained death. Percent of grievances filed by participants that were resolved within 14 calendar days according to approved waiver guidelines. Data source: Record reviews, onsite Data collection responsible party: MCO. Frequency of data collection: Monthly. Sampling: 100% review. Data aggregation responsible party: DOH. Frequency of data aggregation and analysis: Monthly. Percent of participants who received information on how to report the suspected abuse, neglect, or exploitation of adults. Data source: Record reviews, onsite. Data collection responsible party: MCO. Frequency of data collection: Continuously and ongoing. Sampling: Representative sample, 95% CI Data aggregation responsible party: MCO and DOH. Frequency of data aggregation
and analysis: Continuously and ongoing. Percent of reports related to abuse, neglect and exploitation of participants where an investigation was initiated within the established timeframe. Number and percent of substantiated cases of abuse, neglect and exploitation where recommended actions to protect health and welfare were implemented. Data source: MCO abuse, neglect, or exploitation database. Data collection responsible party: MCO. Frequency of data collection: Monthly. Sampling: 100% review. Data aggregation responsible party: DOH. Frequency of data aggregation and analysis: Monthly. The State demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further similar incidents to the extent possible. Number and percent of participants’ critical incidents that were reported, initiated, reviewed and completed within required timeframes as specified in the approved waiver. Data source: MCO critical incidents database Data collection responsible party: MCO. Frequency of data collection: Monthly. Sampling: 100% review. Data aggregation responsible party: MCO.
Frequency of data aggregation and analysis: Monthly. The State policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed. Number and percent of unauthorized uses of restrictive interventions that were appropriately reported. Data source: MCO restrictive interventions database or records review, on-site Data collection responsible party: MCO. Frequency of data collection: Monthly. Sampling: 100% review. Data aggregation responsible party: MCO. Frequency of data aggregation and analysis: Monthly. The State establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver. Number and percent of HCBS participants who received physical exams consistent with state HCBS policy. Data source: MCO encounter data database Data collection responsible party: MCO. Frequency of data collection: Monthly. Sampling: 100% review. Data aggregation responsible party: MCO. Frequency of data aggregation and analysis: Monthly.
3 The State demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants. Service plans address all participants’ assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means. Percent of participants reviewed with a POC that was adequate and appropriate to their needs and goals (including health goals) as indicated in assessment(s) Percent of participants reviewed with a POC that had adequate and appropriate strategies to address their health and safety risks as indicated in the assessment(s). Percent of participants reviewed with a POC that addressed the participant's goals/needs as indicated in the assessment(s). Data source: Record reviews, onsite or through Utilization Review Unit. Data collection responsible party: MCO. Frequency of data collection: Continuously and ongoing. Sampling: Representative sample, 95% CI Data aggregation responsible party: MCO and DOH. Frequency of data aggregation and analysis: Monthly. Service plans are updated/revised at least annually or when warranted by changes in participant’s needs. Percent of participants whose POC was updated within 365 days of the last evaluation. Percent of participants whose POC was updated as warranted by changes in the participant's needs. Data source: MCO database. Data collection responsible party: MCO. Frequency of data collection: Ongoing. Sampling: 100% review. Data aggregation responsible party: MCO. Frequency of data aggregation and analysis: Quarterly.
Services are delivered in accordance with the service Plan, including the type, scope, amount, duration, and frequency specified in the service plan. Percent of new participants receiving services according to their POC within 45 days of approval of their POC. Percent of participants who received services in the type, amount, duration, and frequency specified in the POC. Data source: Person-centered Plan record reviews financial records. Data collection responsible party: MCO. Frequency of data collection: Quarterly. Sampling: Representative sample, 95% CI. Data aggregation responsible party: MCO. Frequency of data aggregation and analysis: Semiannually. Participants are afforded choice between/among waiver services and providers. Percent of participant records reviewed with a completed, signed freedom of choice form that specifies choice was offered among waiver services and providers. Percent of participants reviewed with a POC that includes the participant's and/or guardian/caregiver's signature as consistent with state and federal guidelines. Data source: Record reviews, onsite. Data collection responsible party: MCO. Frequency of data collection: Continuously and ongoing. Sampling: Representative sample, 95% CI. Data aggregation responsible party: MCO and DOH. Frequency of data aggregation and analysis: Semi-annually. 4 Qualified providers: Providers meet required qualifications. The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards Percent of waiver providers providing waiver services who meet licensure and certification requirements prior to furnishing waiver services — initially. Data source: MCO credentialing files. Data collection responsible party: MCO. Frequency of data collection: Continuously and ongoing.
prior to their furnishing waiver services. Percent of waiver providers providing waiver services who meet licensure and certification requirements prior to furnishing waiver services — continuously. Percent of waiver providers providing waiver services who have an active agreement with the MCO. Sampling: 100% review. Data aggregation responsible party: MCO. Frequency of data aggregation and analysis: Quarterly. Note: The State and CMS may want the data stratified by licensed, certified and atypical to ensure that they can pinpoint deficiencies in MCO credentialing. The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements. Percent of providers of waiver services who meet training requirements — provider, training requirements. Data source: Training verification records. Data collection responsible party: MCO. Frequency of data collection: Monthly. Sampling: 100% review. Data aggregation responsible party: DOH. Frequency of data aggregation and analysis: Quarterly. Note: New York may be able to combine PMs in this and the next However, the State and CMS may want the data stratified by licensed, certified and atypical to ensure that they can pinpoint deficiencies in MCO training.
The State implements its P&Ps for verifying that provider training is conducted in accordance with State requirements and the approved waiver. Percent of providers of waiver services who meet training requirements — all providers, ongoing training requirements. Data source: Training verification records. Data collection responsible party: MCO. Frequency of data collection: Monthly. Sampling: 100% review. Data aggregation responsible party: DOH. Frequency of data aggregation and analysis: Quarterly Number of provider trainings operated by the MCO. Data source: Training verification records. Data collection responsible party: MCO. Frequency of data collection: Quarterly. Sampling: 100% review. Data aggregation responsible party: DOH. Frequency of data aggregation and analysis: Quarterly.
Attachment D: MCO and HARP Staffing Grid Section 3.3 Position/Role Dedicated to product line(s)? Can Plan propose to share across MCO and HARP? Must be full-time? NYS Location Requirements Qualified Mainstream Plan Key Personnel with Notification Requirements Plans must designate one of the key personnel positions to have overall accountability for the 1) Mainstream MCO product line and 2) (if offered) the HARP product line K.i. Behavioral Health Medical Director Depends on size of HARP Yes, if Plan has a HARP with less than 4,000 HARP eligibles Yes, if Plan has a HARP with more than 4,000 HARP eligibles Yes NYS license as a physician. A minimum of 5 years of experience is required in a clinical or managed care setting (at least 2 of which are in a clinical setting). Appropriate training and expertise in general psychiatry and addiction disorders (e.g., board certification in general psychiatry and certification in addiction medicine or certification in the subspecialty of addiction psychiatry). K.ii Qualified Mainstream MCO Behavioral Health Clinical Director Depends on size of HARP Yes, if Plan has a HARP with less than 4,000 eligibles Yes, if Plan has a HARP with more than 4,000 HARP eligibles Yes NYS license as BHP. 7 years experience in BH MC or BH clinical setting including at least 2 years of MC experience (preferably Medicaid MC).