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 and Management Yes — Health Home per 1945 of Social Security Act No Managed care for MCO enrollees; FFS for nonMCO enrollees Yes for MCO 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 Rehabilitation services for residential SUD treatment supports (OASAS service) No Rehabilitation option per 42 CFR 440.130 No FFS 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 Yes for MCO enrollees in year 2
Table 4. Appointment Availability Standard by BH Service Type Service Type Emergency Urgent MH/SUD BH Specialist Follow-up to emergency or hospital discharge Follow-up to jail/prison discharge MH Outpatient Clinic/PROS Clinic Within 24 hrs Within 1 wk Within 5 days of request Within 5 days of request ACT Within 24 hrs for AOT n/a Within 5 days of request PROS Timeframe to be determined Within 2 wks Within 5 days of request Timeframe to be determined Continuing Day Treatment 2-4 wks Timeframe to be determined IPRT 2-4 wks Partial Hospitalization Within 5 days of request Inpatient Psychiatric Services Upon presentation CPEP Upon presentation OASAS Outpatient Clinic Within 24 hrs Within 1 wk of request Within 5 days of request Timeframe to be determined Detoxification Upon presentation SUD Inpatient Rehab Upon presentation Within 24 hrs Opioid Treatment Program Within 24 hrs Within 5 days of request Rehabilitation services for residential SUD treatment supports 2-4 wks Within 5 days of request 1915(i)-like Home and Community Based Services Rehabilitation and Habilitation n/a n/a Within 2 weeks of request Within 5 days Crisis Intervention/Respite Immediately Within 24 hours for short term respite n/a Immediate urgent
The percent of annual determinations where level of need criteria were correctly applied. (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) 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.
are followed. 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 1915(i)-like 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 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
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). 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 prior to their furnishing waiver services. Percent of waiver providers providing waiver services who meet licensure and certification requirements prior to furnishing waiver services — initially. 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 Data source: MCO credentialing files. Data collection responsible party: MCO. Frequency of data collection: Continuously and ongoing. 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
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. 5 Administration and operation: The State Medicaid Agency (SMA) retains ultimate authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by contracted entities. Number and/or percent of aggregated performance measure reports generated by the MCO and reviewed by the DOH that contain discovery, remediation, and system improvement for ongoing compliance of the assurances. Number and/or percent of MCO administrative and quality assurance reports approved by DOH prior to implementation by the MCO. Data source: Reports to DOH on delegated administrative functions. 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. 6 Financial accountability: The DOH maintains financial accountability through payment of claims for services that are authorized and furnished to 1915(i)-like participants by qualified providers. The State must demonstrate The State provides evidence that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver and only for services rendered. Percent of providers who have payment recouped for waiver services without supporting documentation. Data source: Routine Medicaid claims verification audits. Data collection responsible party: MCO. Frequency of data collection: Continuously and ongoing. Sampling: 90% CI. Data aggregation responsible party: MCO. Frequency of data aggregation
that it has designed and implemented an adequate system for insuring financial accountability of the waiver program. and analysis: Continuously and ongoing. Percent of claims verified through the MCO's compliance audit to have paid in accordance with the participant's waiver treatment Plan. Data source: MCO's compliance report. Data collection responsible party: MCO. Frequency of data collection: Quarterly or Continuously and On-going. Sampling: 95% CI. Data aggregation responsible party: MCO and DOH. Frequency of data aggregation and analysis: Quarterly. The State provides evidence that rates remain consistent with the approved rate methodology throughout the five-year waiver cycle. The State pays the MCO actuarially sound rates. N/A to MCO reporting.