The Practicalities of Collaboration

1
The Practicalities of Collaboration

• Mary Wherry, RN, MS
• Deputy Administrator
• Nevada Medicaid/SCHIP

2
Collaboration for Change A Medicaid Perspective

• Identify your funding stream(s)
• Learn the rules of the payer(s)
• Create an opportunity to engage the payer(s)
• Perception is reality facilitate the situation
  for the payer to understand your reality use
  their language, when possible
• BE PREPARED to make a commitment

3
Commitment

• Flexibility working with federal, state, and
  local regulations that guide our various agencies
  makes this difficult
• Tolerance relationships take time patience
• Resources time, money, travel
• Creativity partners may have a different
  process focus on the outcome
• Enormous effort and hard work keep focused on
  were here for the kids

4
Medicaid is a Key Player

• Children in foster care are eligible for Medicaid
• Medicaid pays for all health care needs of the
  child
• Medicaid is the primary funding stream for
  childrens mental health
• 36-62 or more of children in foster care have
  some mental health need

5
Medicaid Who Gets It?

• There can be no doubt but that the statutes and
  provisions in question, involving the financing
  of Medicare and Medicaid, are among the most
  completely impenetrable tests within human
  experience. Indeed, one approaches them at the
  level of specificity herein demanded with dread,
  for not only are they dense reading of the most
  tortuous kind, but Congress also revisits the
  area frequently, generously cutting and pruning
  in the process and making any solid grasp of the
  matters addressed merely a passing phase.
• Rehabilitation Association of Virginia v.
  Kozlowski, 42 F.3d 1444, 1450 (4th Cir. 1994)
  (Ervin, Chief Judge)

6
Medicaid Unique by State

• If youve seen one Medicaid program, youve seen
  one Medicaid program.
• A person eligible in one State may not be
  eligible in another State.
• Services provided by one State may differ
  considerably in amount, duration, or scope from
  services provided in a similar or neighboring
  State.
• State legislatures may change Medicaid
  eligibility, services, and/or reimbursement
  during the year.

7
Medicaid State Plan

• State Plan - The Medicaid State Plan defines how
  each state will operate its Medicaid program. It
  includes eligibility and service options elected
  by the State.
• States Choose an eligibility State Plan
• Medically Needy
• Categorically Needy
• - Special Groups

8
Medicaid Program Flexibility

• States choose to
• Establish their own eligibility standards
• Determine the type, amount, duration, and scope
  of services
• Set the rate of payment for services and
• Administer their program

9
General Medicaid Rules

• Comparability of Services
• Free Choice of Provider
• Statewideness
• Utilization Control
• Medical Necessity
• Proper efficient administration
• Payment for services furnished outside the State
• Assurance of Transportation
• EPSDT States are required to provide all
  medically necessary services. This includes
  services that would otherwise be optional
  services or non state plan.

10
Medicaid Waivers

• 1115 Demonstration waivers
• 1915(c) Home and Community Based Waivers
• HIFA Health Insurance Flexibility and
  Affordability

11
Medicaid Resource Tool

• cms.hhs.gov
• Medicaid At-a-Glance A Medicaid Information
  Source
• Download or order

12
Stakeholders Common to Child Welfare and Medicaid

• Providers
• Advocates
• Consumers
• Contractors
• State Agencies
• County Agencies
• Judicial System
• Key legislators
• The feds CMS, ACF, SAMHSA, IHS

13
THE Behavioral Health Redesign

• Chapter 400 http//dhcfp.state.nv.us
• Medicaid Services Manual
• Combined various mental health chapters into one
  chapter
• Includes traditional outpatient mental health,
  mental health rehab option, inpatient psych and
  RTC
• Targeted case management is in Chapter 2500

14
Redesign Summary

• Wraparound Services
• Reorganized levels of care for Treatment Foster
  Care and Group Homes
• Client-centered, family-driven practices,
  culturally competent services
• Developed and maintained with input of all
  stakeholders
• Collaborative interagency and interdisciplinary
  approach

15
Redesign Continued

• System that promotes clinical and therapeutic
  flexibility
• Effective outcome measures
• Quality assurance/Quality Improvement program
• Sustainable stakeholder involvement
• Still waiting for CMS approval of our State Plan
  amendment (sigh)

16
Inclusion

• Weekly stakeholder and provider conference calls
• Ongoing provider training
• Participation in Statewide committees that
  interface with the Redesign
• Behavioral Health Webpage with FAQs
• Published list of all Behavioral Health Medicaid
  providers

17
Inclusion Continued

• Development of a Department-wide Mental Health
  Steering Committee
• Care coordination across providers along the
  continuum of care
• Direct involvement of the Medicaid UM vendor with
  providers with local Program Representatives to
  address issues such as prior authorization,
  payment, billing, and procedural problems

18
Next Steps

• Unresolved works in action
• Dually diagnosed children with special health
  care needs, e.g. SED/MR/RC
• Over utilization of RTCs
• Expanding inclusion to parent groups that werent
  at the table during the redesign
• Enforcement of quality expectations for providers
  and agencies

19
Data

• Collection
• Sorting
• Analysis
• Improvement Opportunities
• Using data to build Executive and Legislative
  Branch support for funding

20
Next Steps for Medicaid

• Deficit Reduction Act
• Section 6062
• Section 6063
• Section 6064
• Section 6081
• Section 6086

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The End (whew)Q A