Improving the Coordination of Services for Adults with Mental Health and Substance Use Disorders: Profiles of Four State Medicaid Initiatives. III. Summary of Selected State Programs

02/27/2015

Within the specific context of their service systems and needs of their communities, each state is implementing very different strategies to improve the coordination of care. This chapter presents a brief synopsis of each state program (detailed information about each state is provided in Appendices A-D). Table III.1 summarizes the key features of these programs.

A. Illinois--Medicaid-Funded Care Coordination Entities that Foster Partnerships among Local Providers

In 2013, Illinois launched the first of six regional Care Coordination Entities (CCEs)--new partnerships of existing community-based providers that include behavioral health, physical health, housing, and social service agencies. The state Medicaid agency, which oversees the CCEs, auto-enrolled between 1,000 and 1,500 Medicaid beneficiaries with complex health needs in each CCE and pays a per-member per-month (PMPM) coordination fee. The CCEs have the flexibility to use the PMPM fee to cover costs of their choosing, although they primarily use it to cover those costs associated with care coordination services. The state hopes that this flexibility will encourage the CCEs to find the most cost-effective way to improve care and lower overall costs for this population. Payment for all other Medicaid services is covered separately through a fee-for-service arrangement. The state has judged that, for individuals with complex medical needs, it is more effective to coordinate care and services in person than by telephone. It is using this initiative to test providers' capacity for developing cost-effective models for delivering in-person care coordination. Ultimately, the state hopes the MCOs will find the CCE model appealing and will contract with them to coordinate care for their members.

B. Louisiana--Expansion of Medicaid Behavioral Health Benefits Managed by a Single Statewide Managed Behavioral Health Organization

In 2012, the state contracted with a single statewide managed behavioral health organization (MBHO) to manage all behavioral health services for Medicaid and non-Medicaid adults. This new arrangement is one component of a larger ongoing effort known as the Louisiana Behavioral Health Partnership (LBHP)--a partnership of several state agencies, including the Office of Behavioral Health (OBH) and Medicaid, to improve the accessibility and outcomes of care. Physical health services are managed through separate MCOs, collectively known as the Bayou Health Plans. The MBHO operates under a 1915(b) waiver for a prepaid inpatient health plan, a 1915(c) Home and Community-Based Services Waiver, and a 1915(i) State Plan Amendment. The MBHO operates on an at-risk basis for Medicaid adult behavioral health services and a non-risk basis for behavioral health services for eligible non-Medicaid adults served by the state's public mental health system. In an effort to better coordinate care for people with housing needs, the MBHO also recently took over management of a permanent supportive housing (PSH) program.

C. Massachusetts--Medicaid Managed Care Plan that Covers Coordination Support for Chronically Homeless Individuals in Permanent Supportive Housing

In 2006, the Massachusetts Behavioral Health Partnership (MBHP)--the Medicaid-managed behavioral health care carve-out--implemented the Community Support Program for Ending Chronic Homelessness (CSPECH). This program provides Medicaid reimbursement for community-based coordination support to chronically homeless individuals now in PSH. CSPECH seeks to achieve Medicaid cost savings by serving this high-cost population in housing rather than on the street or in shelters. CSPECH is currently available throughout the state from eight MBHP providers--all of them local partnerships made up of community-based behavioral health and housing providers. Through its capitation, MBHP reimburses CSPECH services, using a flat per-person per-day case rate. Currently, CSPECH is available only to individuals enrolled in the MBHP-covered plan, although the state is encouraging coverage by the other state MCOs.

D. Tennessee--Medicaid Managed Care System with Integrated Behavioral Health Physical Health, and Long-Term Care Benefits

TennCare is a statewide, mandatory managed care program that serves Tennessee's entire Medicaid population under an 1115 demonstration waiver. In 2007, the state began integrating behavioral health services into its managed care contracts. (Previously, a separate MBHO carved out and managed these services.) In 2010, the state began including long-term care services and supports in its managed care contracts. Three MCOs currently operate on an at-risk basis for physical, behavioral health, and long-term care services. By integrating the management of physical and behavioral health services, the state hopes to encourage service coordination at both the plan and provider levels. The MCOs are able to track service utilization across different sectors of care and use that data to coordinate services.

TABLE III.1. Summary of State Strategies for Improving Care Coordination for Medicaid Beneficiaries with Behavioral Health Conditions
  Illinois Louisiana Massachusetts Tennessee
Program name and start date Care Coordination Innovations Project, which funds CCEs; began September 2013. Louisiana Behavioral Health Partnership (LBHP); began March 1, 2012. Community Support Program for People Experiencing Chronic Homelessness (CSPECH); began 2006. TennCare; behavioral health integration; began 2007 (behavioral health services fully integrated by 2009).
Overview The state's Medicaid agency oversees 6 regional CCEs. CCEs are a formal hub of community-based providers representing behavioral health and physical health services, and housing and social service agencies. State contracts with a single statewide MBHO that operates on an at-risk basis for Medicaid adults and manages care (non-risk) for non-Medicaid adults. CSPECH is a Medicaid-reimbursable service that provides total care coordination support to chronically homeless individuals who have been placed in PSH. TennCare is Tennessee's Medicaid program. All managed care contracts integrate physical, behavioral, and long-term care services.
Population Adult Medicaid beneficiaries with complex health needs, including those with mental health and SUDs. Most clients are auto-enrolled; voluntary selection allowed. All Medicaid and non-Medicaid adults enroll in the MBHO. Supportive housing is available to Medicaid adults who qualify for 1915(i) or Ryan White services. Chronically homeless adults who have been placed in supportive housing and served by the MBHP, the state's MBHO. All Medicaid beneficiaries in the state.
Financing and Medicaid funding authority CCEs receive a PMPM coordination fee, supported through a mix of state and federal funds, through a 3-year state contract. States makes prepaid capitated payments to the MBHO for behavioral health services for Medicaid adults and fixed payments for non-Medicaid adults. It is authorized through a 1915(b) waiver, a 1915(c) waiver, and a 1915(i) State Plan Amendment for adults with SMI. CSPECH offers a type of community support program service for which the state receives CMS approval for reimbursement through its managed care waiver. All state MCOs are approved to provide this level of care; currently onlyMBHPcovers this service. TennCare makes capitated payments for Medicaid beneficiaries. It operates under a 1115 waiver.
Mechanism(s) for coordinating behavioral health and physical services CCEs formalize a partnership between local behavioral health, physical health, and other providers. Care coordination teams work for the CCE, thus operating across sectors. Coordination requirements are embedded in the managed care contract. CSPECH services are provided by community support workers (CSWs) who coordinate behavioral and physical health care services. Management of physical and behavioral health care services occurs under the same MCO contract.
Mechanism(s) for coordinating behavioral health and housing services CCEs include housing and social service providers and care coordination teams, including members with housing experience. PMPM payments could fund non-Medicaid reimbursed supports, although the 2 CCEs interviewed are not currently doing so. PSH couples housing and behavioral health services. Management of PSH services is integrated into the managed care contract so that behavioral health or long-term care services can be funded through Medicaid. CSPECH is part of the state's Housing First initiative; services require a partnership between a behavioral health provider and a housing provider. When a housing unit is available within the partnership, the CSW works with local shelter staff to identify a potential beneficiary. The TennCare Medicaid-supported housing benefit funds housing support services in supervised group homes for eligible beneficiaries.

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